In situ replacement of arterial prosthesis infected by bacterial biofilms: Long-term follow-up

Purpose: Bacterial biofilm infections of vascular prostheses are characterized by an absence of systemic sepsis, a fluid-filled cavity surrounding the graft, a draining sinus tract, and microorganisms that must be removed from the fabric prosthesis for bacterial culture.Methods: Since 1987 we have treated 20 infected grafts with prosthetic excision and in situ replacement in 14 men and 6 women. The time from initial graft implantation to diagnosis of graft infection ranged from 3 months to 14 years (mean 4.5 years). The original graft (Dacron-17, polytetrafluoroethylene-3) was an aortobifemoral in 14, axillofemoral femorofemoral in 3, iliofemoral in 2, and femoropopliteal in 1 patient. Presenting symptoms were groin false aneurysm with perigraft fluid in 10, inflammatory mass in 6, and sinus tract in 4. At surgery all unincorporated graft material and the perigraft capsule were excised from a point where the proximal graft was incorporated, including debridement of vessels at the distal anastomosis. Of the 14 aortobifemoral grafts, only the femoral limbs were excised at the initial presentation of biofilm infection. The conduit was replaced with an in situ polytetrafluoroethylene interposition graft, which was covered with a gracilis or sartorius muscle flap when possible.Results: All surgical sites healed, all grafts remained patent, and there was no limb loss. After ultrasonic oscillation of the explanted graft, bacterial cultures recovered coagulase-negative Staphylococcus species in 14, coagulase-positive Staphylococcus species in one, both species in three, with no growth from two specimens. During follow-up, two patients have had clinical involvement in the proximal intraabdominal portion of the graft that had not been previously resected. In all grafts, the in situ replacement graft remained well incorporated.Conclusion: In situ graft replacement is effective treatment for biofilm infections of vascular prostheses. Because of the indolent nature of these infections, subsequent infection of previously uninvolved graft segments may be expected. (J VASC SURG 1994;19:226-35.)     

Use of cryopreserved femoral vein for in situ replacement of infected femorofemoral prosthetic artery bypass

Isolated groin infection following crossover femoral bypass is not uncommon, and its management may be challenging, especially in medically high-risk patients. When an in situ replacement is appropriate, using an autologous vein (femoral or saphenous) would be the preferred method; however, this may not always be feasible. The authors used cryopreserved femoral vein grafts for in situ replacement of femorofemoral bypass grafts with excellent results in 3 high-risk patients who developed early graft infections and failed graft preservation attempts. In situ replacement of infected femorofemoral grafts using a cryopreserved femoral vein graft can be considered as a second-line intervention when an adequately sized autologous vein is unavailable or unusable or is not feasible in high-risk patients.     

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.     

Freshly harvested cadaveric venous homografts as arterial conduits in infected fields

Six patients with patent multilevel prosthetic grafts (three axillofemoral-femoral grafts, an aortobifemoral graft, an axillofemoral and femoral-anterior tibial graft, and an axillofemoral and femoral-popliteal graft) that demonstrated overt infection involving both the proximal inflow (one infrarenal aorta, five axillary arteries) and groin anastomoses required complete graft excision. Cadaveric inferior vena cava, common and external iliac, common and superficial femoral, and greater saphenous veins were harvested in conjunction with multiple organ donor procedures. Identical anatomic reconstruction within the infected fields was accomplished, with patency and distal perfusion maintained for intervals sufficient to achieve complete resolution of infection in all cases. This interval of revascularization with a venous homograft has served as a temporizing maneuver, which permitted eradication of infection and allowed subsequent reimplantation of prosthetic graft material without associated reinfection in the two instances in which it was required. Use of freshly harvested large-caliber caval, iliac, and femoral homograft veins as arterial substitutes in infected fields has not been previously reported. Case histories and a review of the venous homografting literature are included.     

Obturator bypass: a classic approach for the treatment of contemporary groin infection

As the number of cardiac and interventional radiologic procedures has risen, the frequency with which surgeons are called to treat groin complications has increased. Infectious groin problems that often involve foreign prosthetic material or remnants of percutaneous femoral closure devices are particularly challenging and require control of bleeding, removal of foreign material, wide debridement, and sometimes arterial resection. Management of the consequential limb ischemia in such cases is controversial. The purpose of this study is to review the utility of extra-anatomic common femoral bypass through the obturator foramen (obturator bypass) as a method of treating limb ischemia after arterial groin infection. From July 1992 through June 2001 a total of 12 patients (six male) presented with severe vascular infections of the groin and underwent obturator bypass. Infections occurred as a consequence of an isolated vascular graft infection (nine) or after a percutaneous interventional femoral access procedure (three). Patients presented with systemic sepsis and a draining sinus (six), infected pseudoaneurysm (two), or hemorrhage (four). Treatment included debridement of the groin wound, sartorius muscle flap coverage of the femoral vessels, antibiotics and synthetic (eight polytetrafluoroethylene and four Dacron) obturator bypass via a lower abdominal extraperitoneal incision from an aortobifemoral bypass graft limb to the superficial femoral artery (six), native iliac to femoral artery (three), iliac to popliteal artery (two), and aortobifemoral bypass limb to the popliteal artery (one). Graft patency and limb salvage were assessed by Kaplan-Meier life table analysis. There were two (17%) deaths (multisystem organ failure at postoperative days 9 and 6) and four major complications (25%) requiring reoperation in the first 30 days. Ten patients (83%) survived, healed their groin wounds, and are infection free. With a mean follow-up of 37 months graft patency and limb salvage at 60 months were 80 and 60 per cent, respectively. There were no late graft infections. We conclude that the obturator bypass is an effective and durable means of revascularization in the presence of the septic groin. This procedure belongs in the armamentarium of all surgeons managing these complications.     

A case against immediate revascularisation after uni- or bilateral removal of infected aortobifemoral (end-to-side) prosthetic grafts. Report based on three cases

More than 75% of the infections of Dacron aortobifemoral grafts occur in the groin. Early removal of the infected limb will enable the vascular surgeon to leave the abdominal part and opposite limb of the graft in place. In aortoiliac occlusive disease and with end-to-side proximal and distal anastomoses, simple removal of the infected graft will not threaten the viability of the limb. Complicated and often incomplete extra-anatomical revascularisation is therefore not necessary and consequently operative time and risk are reduced. Close pre- and postoperative monitoring of the peripheral circulation and painstaking decubitus prophylaxis are mandatory. After 3 to 6 months "in situ" bypass can be performed to correct claudication. Three patients that have been successfully treated according to this philosophy are presented.     

Arterioureteral fistula. An unusual cause of aortofemoral bypass infection. A case report

We report a case of arterioureteral fistula after aortobifemoral bypass surgery and prolonged bilateral double J stents due to ureteral stenosis. A 70-year-old woman presented with a non-tender mass in the left groin and a single episode of haematuria 2 months earlier. A Computed Tomography (CT) revealed a pseudoaneurysm of the left distal suture of the graft. Surgical repair was performed. Because of suspicion of infection the entire aortobifemoral graft was removed and replaced by an autologous venous aortofemoral bypass to the right groin and femorofemoral crossover bypass from the right to the left. During surgery an arterioureteral fistula could be visualized. The urologists performed a left nephroureterectomy of the afunctional left kidney. The further postoperative course was uneventful during the 10 months of follow up.     

Influence of Patient Characteristics and Treatment Options on Outcome of Patients with Prosthetic Aortic Graft Infection

This study was undertaken to determine the influence of patient characteristics and treatment options on survival and limb loss after treatment of prosthetic aortic graft infection. Fifty-three patients treated for prosthetic aortic graft infection were reviewed. Twenty-three presented with groin infection, 12 with sepsis, 10 with aortoenteric fistula, 4 with limb ischemia, and 4 with pseudoaneurysm. Treatment included staged extraanatomic bypass (EAB) plus graft excision in 23 patients, simultaneous EAB and graft excision in 18, in situ graft replacement in 5, and local therapy only in 7. Axillofemoral bypass was done for revascularization in 53 limbs and axillopopliteal bypass in 16 limbs. The results of this study showed that morbidity and mortality of prosthetic aortic graft infection is influenced by the presentation and type of treatment of the infected graft. Staged axillofemoral bypass (when possible) plus graft excision appears to be associated with acceptable outcome (survival with limb salvage in 74%).     

Intra-abdominal aortic graft infection: complete or partial graft preservation in patients at very high risk

BACKGROUND: Total graft excision with in situ or extra-anatomic revascularization is considered mandatory to treat infection involving the body of aortic grafts. We present a series of nine patients with this complication and such severe comorbid medical illnesses or markedly hostile abdomens that traditional treatments were precluded. In these patients selective complete or partial graft preservation was used. METHODS: Over the past 20 years we have treated nine infected infrarenal aortic prosthetic grafts with complete or partial graft preservation, because excision of the graft body was not feasible. In all nine patients infection of the main body of the aortic graft was documented at computed tomography or surgery. Essential adjuncts included percutaneous or operative drain placement into retroperitoneal abscess cavities and along the graft, with instillation of antibiotics three times daily, repeated debridement of infected groin wounds, and intravenous antibiotic therapy for at least 6 weeks. RESULTS: One patient with purulent groin drainage treated with complete graft preservation died of sepsis. One patient with groin infection treated with complete graft preservation initially did well, but ultimately required total graft excision 5 months later, after clinical improvement. In four patients complete graft preservation was successful; two patients required excision of an occluded infected limb of the graft; and one patient underwent subtotal graft excision, leaving a graft remnant on the aorta, and axillopopliteal bypass. In summary, seven of nine patients survived hospitalization after complete or partial graft preservation; amputation was avoided in all but one patient; and no recurrent infection developed over mean follow-up of 7.6 years (range, 2-15 years). CONCLUSIONS: Although contrary to conventional concepts, partial or complete graft preservation combined with aggressive drainage and groin wound debridement is an acceptable option for treatment of infection involving an entire aortic graft in selected patients with prohibitive risks for total graft excision. This treatment may be compatible with long-term survival and protracted absence of signs or symptoms of infection.     

Use of rifampin-soaked gelatin-sealed polyester grafts for in situ treatment of primary aortic and vascular prosthetic infections

BACKGROUND: In situ treatment of artery/graft infection has distinct advantages compared to vessel excision and extra-anatomic bypass procedures. Based on animal studies of a rifampin-soaked, gelatin-impregnated polyester graft that demonstrated prolonged in vivo antibacterial activity, this antibiotic-bonded graft was used selectively in patients for in situ treatment of low-grade Gram-positive prosthetic graft infections or primary aortic infections not amenable to excision and ex situ bypass. METHODS: In a 5-year period (1995-1999), 27 patients with prosthetic graft infection (aortofemoral, n = 18, femorofemoral, n = 3; axillofemoral, n = 1) or primary aortic infection (mycotic aneurysm, n = 3; infected AAA, n = 2) underwent excision of the infected vessel and in situ replacement with a rifampin soaked (45-60 mg/ml for 15 min) gelatin-impregnated polyester graft. All prosthetic graft infections were low grade in nature, caused Gram-positive bacteria (Staphylococcus epidermidis, 16; Staphylococcus aureus, 5; Streptococcus, 1), and were treated electively. Patients with mycotic aortic aneurysm presented with sepsis and underwent urgent or emergent surgery. RESULTS: Two (8%) patients died-1 as a result of a ruptured Salmonella mycotic aortic aneurysm and the other from methicillin-resistant S. aureus infection following deep vein replacement of an in situ replaced femorofemoral graft. No amputations or late deaths as the result of vascular infection occurred in the 25 surviving patients. Two patients developed recurrent infection caused by a rifampin-resistant S. epidermidis in a replaced aortofemoral graft limb and were successfully treated with graft excision and in situ autogenous vein replacement. Eighteen patients remain alive and clinically free of infection after a mean follow-up interval of 17 months. CONCLUSIONS: In situ replacement treatment using a rifampin-bonded prosthetic graft for low-grade staphylococcal arterial infection was safe, durable, and associated with eradication of clinical signs of infection. Failure of this therapy was the result of virulent and antibiotic-resistant bacterial strains.     

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.     

Removing the Infected Aortofemoral Graft Using a Two-Stage Procedure with a Delay Between the Stages

This study describes the results of a procedure for removing the infected aortofemoral graft using a two-stage procedure with a delay between the stages. The objective was to lessen the morbidity and mortality associated with removing an infected graft through a single operation. Eight consecutive patients were treated in this manner over a 6-year span. The indications for surgery were infected groin false aneurysms in three, chronic draining sinuses involving the prosthetic graft in four, and an open groin infection involving graft in one. There were five males and three females, with ages ranging 47-83 years (mean = 63). The mean operative time of the first-stage operation was 5.1 hr (range 3.0-7.7), and the mean blood transfusion requirement was 1.7 units. The mean operative time of the second stage operation was 3.5 hr (range 3.5-7.6), and the mean blood transfusion requirement was 2.5 units. In six patients, the hospital course was uncomplicated, with a mean hospital stay of 8.4 days for the initial stage and 9.2 days for the second stage. Two patients had complicated postoperative courses with hospital stays of >30 days. There was no operative or graft-related late mortality. No patients were lost to follow-up. One patient died of unrelated causes with a patent graft at 22 months postsurgery. All other patients remain well with patent grafts, without requiring revisions at a mean follow-up of 33 months (range 6-73). A two-stage approach with a delay between the stages may reduce the morbidity and mortality associated with the removal of an infected aortobifemoral graft. Presented at the Canadian Society for Vascular Surgery Annual Meeting, Victoria, British Columbia, Canada, October 24-25, 2003.     

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.     

Obturator foramen bypass--the alternative route for sepsis in the femoral triangle

Obturator foramen bypass has successfully been used to replace an infected groin graft in eight patients. Early replacement of an infected graft is recommended because of the poor results and risks associated with conservative management.     

Anastomotic tensile strength following in situ replacement of an infected abdominal aortic graft

The tensile strength and histologic features of anastomotic bonding were studied prior to and following in situ replacement of aortic vascular prostheses infected by Staphylococcus epidermidis. Sterile (n = 6) and infected (n = 19) Dacron grafts were used to replace the abdominal aorta of 25 dogs. After five weeks, grafts were explanted, and peak tensile force (measured in kilograms) required for anastomotic disruption was measured using a linear gain tensiometer. Anastomotic tensile strength (mean +/- SEM) of infected grafts (5.4 +/- 0.5 kg) was decreased when compared with that of sterile, control grafts (9.0 +/- 0.9 kg). The decreased anastomotic tensile strength of infected grafts was the result of an inflammatory aortitis adjacent to the suture line. Only grafts infected with the study strain of bacteria demonstrated signs of infection. In 19 dogs, the graft infection was treated by graft excision, antibiotic administration, and in situ graft replacement (Dacron or polytetrafluoroethylene prostheses). After five weeks and 12 weeks, anastomotic tensile strength of polytetrafluoroethylene (10.6 +/- 0.6 kg) and Dacron (10.8 +/- 0.5 kg) replacement grafts was similar to that of uninfected control grafts. In situ replacement of vascular prostheses infected by S epidermidis can result in graft healing with normal anastomotic bonding.     

Autogenous venous reconstruction in the treatment of aortobifemoral prosthetic infection

The Authors describe a patient, in whom an infected aortobifemoral Dacron prosthesis was successfully replaced by an autogenous venous graft. A review of the literature is presented and it is concluded that autogenous reconstruction of the infected field represents a feasible alternative to extra-anatomical revascularisation in the treatment of selected patients with vascular prosthetic infection.     

Composite vein graft reconstruction for infected descending aortic prosthesis

We report a case of successful in situ replacement with a superficial femoropopliteal vein panel graft for Dacron graft infection of the thoracic aorta. A 75-year-old man presented with septicemia and pseudoaneurysm caused by methicillin resistant staphylococcus aureus 2 years after Dacron graft replacement of the mid-descending aortic aneurysm. The patient underwent in situ replacement with a panel graft constructed of 3 deep vein panels after excision of the infected Dacron graft. The patient is free of infection and doing well over 2 years after surgery.     

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.     

Management of infected hemodialysis access grafts using cryopreserved human vein allografts

BACKGROUND: One of the most feared complications of dialysis access is prosthetic arteriovenous (AV) graft infection, which is typically treated with AV graft removal followed by a staged dialysis graft placement elsewhere. Such a treatment approach often presents a challenge since many hemodialysis-dependent patients have limited venous access that may preclude a new AV graft or dialysis catheter placement. In this article, we review the management of AV graft infection using in situ cryopreserved human vein allografts. DATA SOURCES: Functional and antigenic characteristics as well as the clinical experience of cryopreserved human vein allograft in dialysis access are reviewed. Surgical technique of in situ cryopreserved human allograft placement for infected prosthetic AV graft is also described. CONCLUSIONS: Cryopreserved vein allograft is an acceptable graft conduit in difficult hemodialysis access situations. It offers surgeons the ability to deal with the infected graft in one operative procedure with low incidence reinfection and graft patency similar to conventional prosthetic graft replacement.     

Aortic paraprosthetic infection. Diagnostic and therapeutic difficulties. Apropos of a case

Despite advances in vascular surgical techniques and antimicrobial therapy, aortic graft infection remains a difficult clinical problem to manage. We report a case of secondary paraprosthetic fistula. All complementary investigations were negative and the fistula was diagnosed by laparotomy. In situ replacement of the infected graft was decided despite signs of infection. The postoperative course was complicated by septic shock, successfully treated by organism-specific antibiotic therapy. In conclusion, complementary investigations should not delay laparotomy in patients with a aortic prosthesis presenting with unexplained infection. They must be considered to be suffering from a graft infection until proven otherwise. Conditions in situ replacement of the graft appears to be possible under these.