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.     

Infected femorodistal bypass: is graft removal mandatory?

Infected lower extremity bypass grafts have been associated with high rates of limb loss. Traditionally treatment has included graft excision. To compare aggressive local treatment, without graft removal, with more conventional graft excision, we reviewed 38 consecutive patients with 39 infected lower extremity bypasses treated during the last 10 years. The grafts used were prosthetic in 33 cases, vein in 4, and composite in 2. Median follow-up was 2.7 years. Twenty-eight infected grafts were treated with either complete (14) or partial (14) graft removal. Nine new grafts were placed. Recurrent infection developed in five cases, and two patients died of complications of graft infection. Ten of 20 limbs at risk were lost. Eleven patients with patent bypasses (4 vein, 2 composite, 5 prosthetic) were treated without graft excision. Treatment of five patients in this group included muscle transposition. Five patients were treated with incision and drainage of abscesses, and one had excision of a persistent sinus tract. One patient underwent major amputation 6.3 years after treatment of graft infection. Limb salvage was significantly higher (p = 0.012, log-rank test) than in patients treated with graft excision. One patient died, and no recurrent infections developed; these were not significant differences compared with those having graft excision. We conclude that aggressive local treatment of infected lower extremity bypass grafts, including drainage, debridement, and muscle transposition may treat infection in selected patients without the need for graft removal and with rates of limb salvage superior to those obtained with excisional therapy.     

Outcomes in the management of vascular prosthetic graft infections confined to the groin: A reappraisal

The management of vascular prosthetic graft infections confined to the groin continues to be controversial. To critically evaluate this problem, we reviewed the records of our vascular registry from December 1992 through February 1995 and found 17 incidences of groin sepsis involving a vascular prosthesis in 10 patients. These included a proximal prosthetic femoropopliteal bypass (n=6), an aortobifemoral graft limb (n=5), an ileofemoral bypass (n=3), a prosthetic femoral patch (n = 2), and an aortofemoral/femorofemoral bypass (n=1). The mean age of these patients was 65 years. Six patients were diabetic, four were on systemic steroids, and two were diabetic and on steroids. All infections were Szilagyi grade III including three in which the patients presented with local hemorrhage. Treatment consisted of irrigation, radical debridement with or without in situ graft replacement, and local rotational muscle flap coverage in nine cases, graft excision with extra-anatomic (obturator ileofemoral bypass) graft replacement in six cases, and excision alone in two cases. Of the 17 infections treated operatively and followed from 1 week to 18 months (median 5 months), eight (47%) showed no evidence of recurrence, six (35%) recurred, two (12%) caused early death, and one resulted in a thrombosed graft requiring extra-anatomic reconstruction. Of the nine infected grafts treated locally with muscle flaps, six showed recurrent infection from 3 weeks to 15 months and one thrombosed for a total local treatment failure rate of 78%. Only two grafts are free of infection at 4 and 5 months, respectively. Of the six incidences of infection treated with obturator bypass, four (66%) are free of infection and two resulted in patient death; both infections treated with excision alone were eradicated but resulted in a major lower extremity amputation. These data question the growing acceptance of debridement and local muscle flap coverage for the treatment of all prosthetic vascular graft infections confined to the groin, especially in patients who are diabetic or on systemic steroids.Presented at the Twentieth Annual Meeting of the Peripheral Vascular Surgery Society, New Orleans, La., June 10, 1995.     

Selective preservation of infected prosthetic arterial grafts. Analysis of a 20-year experience with 120 extracavitary-infected grafts.

OBJECTIVE: The authors report on their 20-year experience with 120 patients with infected extracavitary prosthetic arterial grafts (95 polytetraflouroethylene, 25 Dacron). Throughout this experience, an effort was made, when appropriate, to salvage all or a portion of these infected grafts. METHODS: When patients had arterial bleeding (20 cases) or systemic sepsis (6 cases), immediate graft excision was performed. When the infected graft was occluded (43 cases), subtotal graft excision was performed, leaving an oversewn 2- to 3-mm graft remnant to maintain patency of the artery. Complete graft preservation was attempted in 51 cases in which the graft was patent, the patient was not septic, and the anastomoses were intact. Aggressive operative wound debridement was repeated, as necessary, to achieve wound healing. The preferred method of revascularization, when necessary, included secondary bypasses tunneled through uninfected (often lateral) routes. Follow-up averaged 3 years (range, 1 month-20 years). RESULTS: This strategy resulted in a hospital mortality of 12% (14/120) and a hospital amputation rate in survivors of 13% (14/106 threatened limbs). Of the surviving patients treated by complete graft preservation, the hospital amputation rate was only 4% (2/45) and long-term complete graft preservation was successful in 71% (32/45) of cases. Partial graft preservation also proved successful in 85% (35/41) of surviving patients who had occluded grafts. Successful complete graft preservation was as likely when gram-negative or gram-positive bacteria were cultured from the wound, with the exception of Pseudomonas (successful graft preservation in only 40% [4/10] of cases). CONCLUSION: Based on this 20-year experience, the authors conclude that selective partial or complete graft preservation represents a simpler and better method of managing infected extracavitary prosthetic grafts than routine total graft excision.     

Treatment strategies for aortic and peripheral prosthetic graft infection

Purpose

The aim of this study was to investigate the outcomes correlated with our treatment strategy for prosthetic graft infection.

Methods

Seventeen patients were treated for prosthetic graft infections between 1997 and 2009. Initially, total graft excision was applied in five cases, partial graft excision was applied in six cases and graft preservation with drainage and irrigation was applied in six cases. Among the graft-preserved cases, four patients were infected with methicillin-resistant Staphylococcus aureus (MRSA) and treated with gentian violet (GV).

Results

The overall survival rate was 88 % at 30 days and 82 % at 1 year in this series. Of the excised cases, nine patients survived; however, two patients died. Among the cases in which MRSA-infected grafts were preserved, three patients survived; however, one patient died under a septicemic state. Infected graft preservation was applied at a high rate of 36 %, and the mortality rate remained at 16 %, without any signs of graft reinfection.

Conclusions

In the treatment of infected grafts, the patient’s condition should be considered in order to select the appropriate treatment in each case. Graft preservation should be considered as an alternative treatment option, especially in high-risk patients, and GV can be effective for conservative treatment of prosthetic graft infections, including MRSA infections.     

Infrainguinal anastomotic arterial graft infections treated by selective graft preservation.

The purpose of this study was to determine whether the type of graft material and bacteria involved in an infrainguinal arterial anastomotic infection can be used as guidelines for graft preservation. Between 1972 and 1990, the authors treated 35 anastomotic infections involving a common femoral or distal artery. The graft material was Dacron in 14 patients, polytetrafluoroethylene (PTFE) in 14, and vein in 7. Of the 14 Dacron grafts, immediate graft excision was required for overwhelming infection in eight patients (bleeding in five, sepsis in three) and for an occluded graft in one patient. Three of five patients failed attempted graft preservation because of nonhealing wounds. Thus, 12 of the 14 Dacron grafts ultimately required graft excision. Of the 21 "smooth-walled" vein and PTFE grafts, 10 required immediate graft excision for occluded grafts (five PTFE, one vein) or bleeding (three PTFE, one vein). Ten of the remaining 11 (91%) patients with patent "smooth-walled" grafts, intact anastomoses, and absence of sepsis managed by graft preservation healed their wounds and maintained distal arterial perfusion. Wound cultures grew pure gram-positive cocci in 17 of 21 "smooth-walled" graft infections versus 8 of 14 Dacron graft infections. In the absence of systemic sepsis, graft preservation is the treatment of choice for gram-positive infections involving an intact anastomosis of patent PTFE and vein grafts. Regardless of the bacterial cause, the authors recommend that any infrainguinal anastomotic infection of a Dacron graft be treated by immediate excision of all infected graft material.     

Total excision and extra-anatomic bypass for aortic graft infection

Reports of high mortality and amputation rates following total excision and extra-anatomic bypass for aortic graft infection have prompted the use of alternate approaches including local antibiotics, partial resection, in situ revascularization, and graft excision without revascularization. Experience with aortic graft infection was reviewed to establish current morbidity and mortality rates and evaluate our bias in favor of total excision and extra-anatomic bypass. Aortic graft infection was identified in 32 patients, 8 with aortoenteric fistulas. The mean interval between graft placement and infection was 34 months. History of groin exposure (75%) or multiple prior vascular surgery (50%) was common. Clinical signs included fever and/or leukocytosis (23 patients), false aneurysm (9 patients), graft thrombosis (6 patients), groin infection (11 patients), and gastrointestinal hemorrhage (6 patients). Microbiologic data, available in 26 patients, demonstrated gram-positive organisms in 15 patients and gram-negative in 9. Multiple organisms were seen in 11 patients. Patients were treated by partial removal with (8 patients) or without (4 patients) revascularization or total removal with (18 patients) or without (2 patients) revascularization. Revascularization was by an extra-anatomic route, either simultaneous or staged. Overall morbidity/mortality was less in the revascularized groups (p = 0.01), while late complications were seen only after partial removal (p less than 0.01). The best results were found after total excision with revascularization. No patient in this group experienced late infection or amputation during a mean follow-up of 34 months (range: 1 to 168 months). Complications after total excision and extra-anatomic bypass for aortic graft infection are lower than generally appreciated. This approach should remain the standard to which other approaches are compared.     

Management of infected lower extremity autologous vein grafts by selective graft preservation.

Between 1975 and 1991, we treated 16 patients with infected lower extremity autologous vein grafts performed for limb salvage by complete graft preservation. Traditional treatment of these infections includes immediate graft excision and complex revascularization procedures to prevent limb loss. The infection involved an intact anastomosis in 12 patients or the body of a patent graft in 4 patients. None of the patients was systemically septic. All patients were treated with appropriate intravenous antibiotics. Six patients were treated by placement of autologous tissue on the exposed graft (4 rotational muscle flaps, 2 skin grafts), and 10 were treated with antibiotic-soaked dressing changes and repeated operative débridements to achieve delayed secondary wound healing. This treatment resulted in a 19% (3 of 16) mortality rate and an 8% (1 of 13) amputation rate in survivors. Of the six patients managed by autologous tissue placement onto the infected graft, five patients had wounds that healed without complications, and one died of a myocardial infarction. Of the 10 patients treated by delayed secondary wound healing, 2 developed anastomotic hemorrhage, which resulted in death in 1 patient and above-knee amputation in the other, 1 died of a myocardial infarction, 1 developed graft thrombosis, and 6 had wounds that healed. Placement of autologous tissue to cover an exposed, infected patent vein graft with intact anastomoses may prevent graft dessication, disruption, and thrombosis, which renders graft preservation an easier, safer method of treatment compared with routine graft excision.     

Management of aortic prosthetic infections

Infections of aortic vascular prostheses remain a dreaded complication. Although removal of the graft has generally been recommended in the literature, the role of lesser procedures, the need for alternate revascularization, and a precise plan of attack are ill defined. We have treated 18 patients with infection of aortic prostheses. Specific risk factors potentially promoting infection included reoperation, septic complications, or gastrointestinal entry at the time of graft placement. Clinical signs of infection included chronic draining sinus in eight patients, localized groin abscess in three patients, groin swelling in four patients, gastrointestinal bleeding in two patients, and pseudoaneurysm in one patient. Treatment by local therapy, including catheter irrigation of sinus tracts, debridement, and local antibiotics, resulted in failure in eight of nine patients. If the sinogram of a groin sinus showed no communication with the body of the graft, resection of a graft limb was successful in 66 percent of the patients. If the sinus communicated with the body of the graft, total resection was mandatory. When total excision was necessary, all patients required revascularization by means of an extraanatomic bypass. The mortality rate was 33 percent and was primarily due to bleeding fistulas. An aggressive approach to this serious problem with early graft excision is encouraged.     

Improved management of infrainguinal bypass graft infection with methicillin-resistant Staphylococcus aureus

BACKGROUND: There is considerable debate over the management of infected infrainguinal grafts. This report describes recent experience in this field and documents the change in clinical practice needed to deal with methicillin-resistant Staphylococcus aureus (MRSA). METHODS: All infected infrainguinal grafts between January 1991 and July 1997 were reviewed. In the light of the findings, clinical practice was modified considerably. A further 1 year was audited prospectively up to August 1998. RESULTS: Twenty-six patients were treated for 27 infrainguinal graft infections (25 prosthetic, two vein). Twenty were treated by complete graft excision as the initial therapy; graft preservation was attempted in six patients. Before 1995, the infecting organisms were predominantly Pseudomonas aeruginosa or methicillin-sensitive staphylococci. Subsequently all 14 patients treated up to 1997 had infection with MRSA. The overall amputation rate was 17 of 26; ten amputations were in patients with MRSA. Four patients died, all with MRSA sepsis. As a result of this experience a policy of complete isolation was adopted for all patients infected with MRSA. In the 12 months since this policy was introduced, 77 infrainguinal grafts (61 vein, 16 prosthetic) have been inserted. Two grafts (3 per cent) have become infected, necessitating graft excision and amputation. CONCLUSION: MRSA infection of an infrainguinal graft is a serious complication with high associated amputation and mortality rates. Isolation and barrier nursing appeared to contain the problem.     

Are gram-negative bacteria a contraindication to selective preservation of infected prosthetic arterial grafts?

Management of infected prosthetic arterial grafts has traditionally included total graft excision especially when gram-negative bacteria were cultured. Between 1973 and 1991 we treated 42 patients with infected prosthetic grafts (33 polytetrafluoroethylene (PTFE), 9 Dacron) by complete graft preservation when the graft was patent, the anastomoses were intact, and the patient did not have sepsis. The infection involved the anastomosis (36 cases) or the body (6 cases) of 33 peripheral grafts and the distal segment of five aortofemoral and four iliac-distal grafts. Cultures of the 42 infected grafts grew gram-positive bacteria in 33 cases and gram-negative bacteria in 22 cases. Treatment adjuncts included repeated, radical operative wound debridement and rarely (7 of 42) rotational muscle flaps. This management resulted in a 10% (4 of 42) hospital mortality rate and an amputation rate in survivors of 3% (1 of 38 threatened limbs). All four deaths were due to sepsis: gram-positive bacteria were cultured in all cases and gram-negative bacteria in two cases. Of the 38 survivors, 29 (76%) wounds healed and remained healed after average follow-up of 3 years (range, 1 to 18 years). Nine other patients required total graft excision for nonhealing wounds (7 cases) or delayed anastomotic hemorrhage (2 cases). Gram-negative bacteria were cultured in four, and gram-positive bacteria were cultured in six of these nine wounds. Four of nine (44%) graft infections that cultured Pseudomonas organisms healed without complications versus 23 of 33 (70%) wounds that cultured gram-positive bacteria, and 12 of 13 (92%) wounds that cultured gram-negative bacteria other than Pseudomonas organisms.(ABSTRACT TRUNCATED AT 250 WORDS)     

TEVAR后移植物感染合并主动脉食管瘘的外科治疗

背景与目的 主动脉食管瘘（AEF）是一种相对罕见的疾病,通常危及生命。尽管胸主动脉腔内修复术（TEVAR）已成为治疗胸主动脉瘤、胸主动脉夹层的一种成熟手术策略,但TEVAR后继发性AEF更为棘手。笔者报告7例该疾病的治疗方式和结果。方法 回顾性分析2018—2021年间收治的7例TEVAR后继发性AEF合并移植物感染患者的临床资料。所有7例患者均接受了介入或手术治疗,其中4例患者施行了开放手术治疗,即：非体外循环下升主动脉－腹主动脉解剖外人工血管旁路术、感染移植物及感染灶切除术、食管瘘口旷置引流术;2例患者施行了TEVAR;1例患者分期施行了TEVAR和开放手术。结果 一期和分期施行开放手术治疗的5例患者,2例痊愈出院,3例死亡。单纯施行TEVAR的2例患者,计划待抗感染、营养支持后限期施行开放手术,治疗期间死亡。结论 因感染移植物及感染灶的存在,保守治疗或单纯行TEVAR往往无法使患者获得救治。虽然开放手术病死率较高,但在条件允许时,清除感染灶及移植物,并进行解剖外主动脉重建及食管瘘旷置引流,是治疗TEVAR术后移植物感染合并主动脉食管瘘的合理策略。     

Treatment for Aortic Graft Infection

Nine patients with an aortic graft infection presented after undergoing aortic grafting. Seven of 9 patients underwent an initial aortic reconstruction in our hospital. The incidence of aortic graft infection was 1.5% (7/456). There were 6 cases of paraprosthetic infection and 3 cases of aortointestinal fistulas. The treatments consisted of a complete graft excision and an axillofemoral bypass in 6 patients, a complete graft excision alone, a partial graft excision and a femorofemoral bypass, and the preservation of the graft with omental wrapping and irrigation in 1 each. Broad-spectrum antibiotics were intravenously administered to all patients and were then replaced by selective antibiotics for the responsible organisms. All surviving patients received antibiotics orally for 3–6 months. The early postoperative mortality rate was 11.1%. Aortoduodenal fistula occurred in 1 patient with graft excision alone. Graft thrombosis occurred in 2 patients with an axillofemoral bypass. No late graft infection or stump blowout occurred in any patient. We believe that a complete excision of the infected graft as well as the maintenance of distal tissue perfusion is necessary. However, based on the condition of the patient, the appearance of the operating field, and the difficulty of a repeat operation, we would like to stress the importance of selecting the best and safest treatment plan for each case. Received: August 26, 1999 / Accepted: July 25, 2000     

Wound infections involving infrainguinal autogenous vein grafts: a current evaluation of factors determining successful graft preservation

PURPOSE: The purpose of this study was to review the natural history and clinical outcome of patients with infrainguinal autogenous graft infection (IAGI), to evaluate the effectiveness of attempted graft preservation, to determine those variables associated with graft salvage, and to better determine optimal treatment. STUDY DESIGN: We retrospectively reviewed the records of patients undergoing infrageniculate vein grafts at three hospitals between 1994 and 2000 who had a wound infection involving the graft. Clinical and bacteriologic variables were analyzed and correlated with graft salvage, limb salvage, and clinical outcome. RESULTS: During this 7-year period, 487 patients underwent an infrageniculate vein graft, and 68 (13%) had clinical evidence of IAGI. Twenty-seven patients presented with drainage from the wound, 15 with wound separation and cellulitis, 18 with soft tissue infection extending to the graft, 4 with an abscess and cellulitis, and 4 with bleeding. Ten patients (15%) had systemic symptoms (defined as a white blood cell count > 15,000 and temperature > 38.5 degrees C). Forty infections developed in the thigh, 17 in the groin, and 11 in the lower leg. An anastomosis was exposed in 15 patients. Wound cultures were positive for bacteria in 52 patients, and most infections were due to Staphylococcus aureus (18 patients) and S epidermidis (12 patients). Pseudomonas was cultured from seven infections. Twelve patients had polymicrobial infections. The interval from operation to infection ranged from 7 to 180 days. All patients were treated with oral antibiotics, 48 after intravenous antibiotics. Forty-five patients had operative debridement, including 18 who had muscle flap coverage. Four patients presented with hemorrhage, and three had immediate graft ligation and one graft excision. Follow-up ranged from 5 to 68 months (mean, 24.3 months), with 61 patients currently alive. Two patients died as a result of the IAGI (mortality rate, 2.9%). One had undergone a below-knee amputation, and one had a nonhealed wound but intact limb. Overall, 61 wounds (91%) healed, 4 patients required below-knee amputations, and 3 wounds did not heal. Fifty-eight grafts remained patent, 6 thrombosed, and 4 were ligated to control hemorrhage. Of the 61 wounds that healed, the time required for healing ranged from 7 to 63 days. No patient with bleeding died because of the acute episode. No patient had delayed hemorrhage. All 18 patients treated with a muscle flap healed. Bleeding (P <.001), elevated white blood cell count (P <.029), fever (P <.001), and renal insufficiency (creatinine level > 1.5; P <.056) were the only variables statistically significant in predicting graft failure or limb loss. With the use of life-table analysis, graft patency was 94%, 72%, and 72% at 1, 3, and 5 years, and limb salvage was 97%, 92%, and 92% at the same intervals, respectively. CONCLUSIONS: Most patients with an IAGI can be successfully treated with graft and limb preservation. In contrast to earlier studies, an exposed anastomosis, interval to infection, or Pseudomonas infection is not associated with graft failure. Graft salvage is less likely in patinets with fever, leukocytosis, and renal insufficency, but because most grafts remained patent, graft preservation is recommended for these patients. Graft ligation or excision should be reserved for patients presenting with bleeding or sepsis.     

Infected prosthetic grafts. Local therapy with graft preservation

Three cases of infected vascular prosthesis in the groin were treated successfully with antibiotics, local debridement, and continuous irrigation of the area with the appropriate antibiotic solution. We describe a system developed to permit steady instillation of antibiotic solution and complete drainage by suction to remove serous and necrotic material. In selected cases of infected vascular grafts, when they have not thrombosed, aggressive local and systemic therapy may control the infection and permit salvage of the prosthesis.     

Management of infected aortic prosthetic grafts

The management of infected prosthetic grafts is one of the most challenging problems facing vascular surgeons. High mortality and morbidity rates with traditional treatment have led many surgeons to consider different and novel strategies. Diagnosis is usually straightforward, but occasionally is unclear even after extensive clinical and radiologic investigations. Although routine total graft excision for all infected aortic grafts is still favored by some vascular surgeons, most favor only partial graft excision if only the distal limb of the graft is involved. Placement of in situ autologous vein or cryopreserved grafts have gained popularity, and investigations are continuing regarding the use of in situ antibiotic and silver-coated prosthetic grafts. In this article the authors review the incidence and etiology of aortic graft infections, methods to prevent these complications, the diagnosis of infected aortic grafts, and lastly the management of these complicated cases, including total graft excision and partial and complete graft preservation.     

Treatment of deep infection following thoracic aorta graft replacement without graft removal

Deep infection following thoracic aortic replacement constitutes an extremely serious and life-threatening complication, and its treatment remains a challenge to surgeons. We report our experience involving five patients in whom deep infection occurred around the graft. Four of the five patients were treated by emergency surgery and one was treated by elective surgery. Surgical procedures performed including hemiarch replacement in one case, total arch replacement in one case, suspension of aortic valve and ascending aorta replacement in one case, Bentall procedure in one case, and descending aorta re-replacement in one case. Methicillin-resistant Staphylococcus aureus was detected in four patients, methicillin-resistant Staphylococcus epidermidis in one, and Aspergillus in one patient from purulent discharge at the operative site. Reoperative debridement and irrigation drainage were carried out at an early phase of infection. Intermittent irrigation following the reoperation was performed in all cases. In addition, muscle flap filling or omental translocation was carried out in three patients. Although the reported principle of treatment for arterial graft infection is extraanatomical bypass or rereplacement after removal of the infected graft, such procedures may be technically difficult and have a high risk at the thoracic level. Local anti-septic irrigation, administration of antibiotics, and vascular-rich tissue filling are useful procedures, and it appears that it is not always necessary to remove prosthetic grafts.     

Conservative treatment of aortic graft infection

Conservative, nonresectional management of aortic graft infections is the optimal management for selected patients with aortic graft infections. The best candidates are those patients who have significant comorbidities, or where the existing aortic graft is in a location that precludes excision without causing a high likelihood of morbidity and/or mortality, such as thoracoabdominal and aortic arch grafts. When considering the conservative approach, computed tomographic angiography, supplemented by Indium(111) leukocyte scanning, is the best combination of diagnostic tests. Contraindications to a conservative approach are infected anastomotic aneurysms, graft-enteric fistulas, and suture-line hemorrhage. Needle aspiration of perigraft fluid or phlegmon, under ultrasound or computed tomography guidance, is useful to both culture the infection and provide drainage. A conservative approach should not be considered when the graft infection is due to invasive Gram-negative organisms, such as Pseudomonas or Salmonella species. Once a conservative approach is selected as the best treatment option, drainage of an infected perigraft space is critical to success, and can be performed either percutaneously or with open surgery, whether an endograft or surgically placed graft is in place. If open drainage is required, the perigraft space should be debrided and catheters placed for long-term antibiotic irrigation. With continuous antibiotic irrigation until the cultures are negative, followed by life-long oral antibiotics, there are multiple case reports and small series of long-term survivors. Whether the aortic graft infection is cured or controlled is debated, but outcomes for high-risk patients and those with grafts in critical vascular beds are often superior to a high-risk surgical graft resection.     

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.     

Prosthetic graft infection, five years after ascending aortic replacement

Fifty-year-old male developed an infected perigraft collection five years following wrapping of a Dacron tube with residual aneurysmal ascending aortic tissue. Treatment consisted of excision of the graft, debridement of the infected surrounding tissues, and replacement using a rifampin-soaked Hemashield tube graft. This case demonstrates the potential risk of wrapping prosthetic grafts with native aneurysmal aortic tissue.