Use of superficial femoropopliteal vein for suprainguinal arterial reconstruction in the presence of infection

BACKGROUND: Conventional treatment of mycotic aneurysms or graft infections of the aortoiliac segment by in situ or extra-anatomic prosthetic reconstruction has a high mortality and morbidity rate, with a substantial risk of persistent graft infection. The use of autologous vein may reduce this. METHODS: Eleven patients with suprainguinal arterial infections including two with mycotic aortic aneurysms, four with aortic graft infections, four infected femorofemoral grafts and an infected axillofemoral graft were treated by debridement and in situ reconstruction with autologous superficial femoropopliteal vein. All patients received appropriate antibiotic therapy and were followed by regular postoperative duplex imaging. Preoperative femoral vein duplex imaging was performed in eight of the 11 patients. RESULTS: Ten of the 11 patients survived with a functioning graft and without limb loss or evidence of infection at 4-33 months. One patient died from myocardial infarction after operation. Three patients had minor swelling of one leg. Four patients required subsequent angioplasty of anastomotic stenoses detected by duplex surveillance. CONCLUSION: Superficial femoropopliteal vein is an excellent conduit for suprainguinal reconstruction in the presence of infection. Duplex imaging is useful for confirming the suitability of deep veins for use as a graft and for postoperative surveillance.     

Management of infected grafts and mycotic aneurysms of the aorta using cryopreserved homografts

OBJECTIVE: To evaluate the efficacy of the treatment of infected prosthetic grafts and mycotic aneurysms of the aorta with cryopreserved homografts. MATERIALS AND METHODS: Between April 1994 and May 2002, 15 cryopreserved aortic homografts were used in 13 patients in the thoracic and abdominal aortic position with supplementary omental or pectoral muscle wrapping for infected grafts (n=11), and mycotic aneurysms (n=2) (mean age: 57.5). RESULTS: One patient died due to multiorgan failure and the other due to postoperative cerebral hemorrhage (15.38%). Another patient died four months after the operation due to septic arthritis, and coronary heart disease. Ten patients are still alive without evidence of infection (76.92%) during a follow up of 44+/-23.03 (range 4-71) months. CONCLUSION: The use of cryopreserved homografts with supplementary omentum and/or muscle flap coverage, assures an anatomical reconstruction with good results in this difficult group of patients.     

Surgical treatment for primary infected aneurysm of the descending thoracic aorta,abdominal aorta,and iliac arteries

OBJECTIVE AND METHOD: In this retrospective review, we report the surgical results of infected aortic aneurysms treated at a single center over 5 years. RESULTS: From October 1996 to October 2001, 19 patients with infected aortic aneurysm were treated with surgery, nine with suprarenal infections (four proximal descending thoracic aortic aneurysms, two distal descending thoracic aortic aneurysms, and three suprarenal abdominal aortic aneurysms) and 10 with infrarenal infections (eight infrarenal abdominal aortic aneurysms and two iliac artery aneurysms). All had a positive blood or tissue culture; 89% were febrile, 89% had leukocytosis, and 32% were hemodynamically unstable. The most common responsible pathogens were Salmonella organisms (74%) followed by Streptococcus species (11%). Nine of 10 infrarenal infections were caused by Salmonella organisms. Both infrarenal and suprarenal infections were treated with wide débridement of infected aorta, in situ prosthetic graft or patch repair, and prolonged intravenous antibiotics. Hospital survival rate was 95%: 100% for infrarenal and 89% for suprarenal infections. There was no perioperative intestinal ischemia or perioperative limb loss. Acute renal failure occurred in two patients with suprarenal infection. Late deaths have occurred in three patients with one early graft infection (5%) resulting in the only one in-hospital death at 4 months. Sixteen patients remain alive at mean follow-up of 17.8 months (range, 4-47 months). There have been no late aortic or graft infections. During the same period, there were five unoperated patients, four of whom died of shock during hospitalization. CONCLUSIONS: Infected aortic aneurysm is common in Taiwan, and Salmonella species were the most common responsible microorganisms. With surgical intervention and prolonged intravenous antibiotics, in situ graft replacement provided a good outcome. The incidence of prosthetic graft infection was low, even in patients with infections due to Salmonella species and with in situ graft replacement.     

Cryopreserved Arterial Allografts for In situ Reconstruction of Infected Arterial Vessels

OBJECTIVE: To review our experience of using cryopreserved allografts for in situ reconstruction in the presence of infection involving the aorta, iliac or femoral arteries. DESIGN: Retrospective clinical study. METHODS: From 3/2000 to 8/2003 all patients with mycotic aneurysms or secondary infection following earlier prosthetic replacement were treated with cryopreserved human allografts. Forty-two patients, 39 (93%) with a prosthetic graft infection and 3 (7%) with a mycotic aneurysm of the abdominal aorta were treated. Six (14%) had aorto-enteric fistulas, 5 (12%) had ruptured aneurysms, and 2 also had vertebral destruction. The median follow-up time was 20 months (range 1-42 months). RESULTS: Thirty-day mortality was 14%. Three patients died due to multi-organ failure, two patients died from hypovolaemic shock due to allograft rupture and one from rupture of the native aorta. The overall mortality was 24% (four additional patients). Graft patency was 100% at 30 days and 97% at follow up in the survivors. The mean actuarial survival time was 32 months (95% CI=27-37 months). CONCLUSIONS: Cryopreserved allografts for the in situ reconstruction of infected arteries or grafts have acceptable intermediate results.     

Patch closure of aortic annulus mycotic aneurysms

Twenty-three patients with bacterial endocarditis and mycotic aneurysms of the aortic annulus were treated between 1978 and 1985. There were 18 men and 5 women ranging from 24 to 72 years old. All patients had congestive heart failure and positive blood cultures as a complication of the endocarditis and were in New York Heart Association (NYHA) Functional Class III or IV. The aneurysm complicated late prosthetic valve endocarditis in 7 patients and native valve endocarditis in 16. The most common infecting organisms were streptococci (12 patients) and staphylococci (7 patients). The noncoronary sinus was the most frequent site for aneurysm formation. Following debridement of the abscess cavity, the orifice of the aneurysm was closed with a patch of Dacron in 20 patients and autologous pericardium in 3. A prosthetic valve (18 bioprosthetic and 5 mechanical) was secured to the noninfected portion of the native annulus and to the patch at the level of annulus. There were 3 deaths, 1 perioperative and 2 late, each without evidence of residual infection or aortic insufficiency. There are 20 late survivors (87%). After a mean follow-up of 1 year, all patients are in NYHA Functional Class I. Patch closure of mycotic aneurysms involving the aortic annulus permits aggressive debridement of the abscess cavity and affords closure of the orifice without tension. The prosthetic valve can be seated at the level of the native annulus, thus avoiding complicated reconstructive procedures of the aortic root and coronary arteries. This technique is an effective alternative in selected cases of mycotic aneurysms involving the aortic annulus.     

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.     

Mid-term results for second-generation thoracic stent grafts

BACKGROUND: Thoracic stent grafts offer an alternative to open surgery for thoracic aortic disease, but their long-term durability is unknown. This report includes mid-term follow-up for commercially available thoracic devices. METHODS: Data were collected prospectively for a series of endoluminal grafts used to treat thoracic aortic pathology. RESULTS: Between July 1997 and October 2002, 67 patients received thoracic stent grafts. Elective procedures incurred a 30-day mortality rate of 2 per cent (one of 42 patients) and urgent repair 16 per cent (four of 25). Paraplegia affected three (4 per cent) of 67 patients and three patients had a stroke. The median follow-up was 17 (range 2-64) months; four patients were lost. There were six late deaths, two from aneurysm rupture (rupture of a mycotic aneurysm at 5 months and stent migration at 28 months). Other device-related complications comprised three proximal endoleaks, one of which required open surgical correction with removal of the stent graft, and two distal endoleaks, which were successfully treated with distal extension cuffs. CONCLUSION: In the mid term, endoluminal repair of thoracic aortic pathology appears to be a safe alternative to open surgery, but continued surveillance is essential.     

Treatment of mycotic aortic aneurysms with endoluminal grafts.

PURPOSE: To report the benefit of endoluminal repair of mycotic aortic aneurysms and highlight the need for a registry. METHODS: Nine patients (five female) were identified over 5 years (1998-2003) as having presumed mycotic aortic aneurysms (12 in total) suitable for endoluminal grafting. A total of nine thoracic and three abdominal were grafted and followed up for a median of 36 months. RESULTS: Six of the aneurysms have resolved and one was converted to an open repair. There was one early death from rupture of a second undiagnosed aneurysm and two late deaths from rupture due to persistent inflammation. Long-term antibiotics have not been mandatory to ensure survival. CONCLUSIONS: Mycotic aortic aneurysms of the thoracic and abdominal aorta do benefit from endoluminal repair, particularly when arising in previously normal aortic tissue. Endoluminal grafting also has a role in the palliation of secondarily infected aortas and so to prove its efficacy in the treatment of all these rare cases a registry is required.     

The results of in situ prosthetic replacement for infected aortic grafts.

BACKGROUND: Treatment of aortic graft infection with graft excision and axillofemoral bypass may carry an increased risk of limb loss, aortic stump blowout, and pelvic ischemia. A review of patients with aortic graft infection treated with in situ prosthetic graft replacement was undertaken to determine if mortality, limb loss, and reinfection rates were improved with this technique. METHODS: The clinical data of 25 patients, 19 males and 6 females, with a mean age of 68 years (range 35 to 83), with aortic graft infection, treated between January 1, 1989, and December 31, 1998, by in situ prosthetic graft replacement were reviewed. Follow-up was complete in the 23 surviving patients and averaged 36 months (range 4 to 103). RESULTS: Twenty aortofemoral, 3 aortoiliac, and 2 straight aortic graft infections were treated with excision and in situ replacement with standard polyester grafts in 16 patients (64%), or with rifampin-soaked collagen or gelatin-impregnated polyester grafts in 9 patients (36%). Fifteen patients (60%) had aortic graft enteric fistulas, 8 patients (32%) had abscesses or draining sinuses, and 2 patients (8%) had bacterial biofilm infections. Thirty-day mortality was 8% (2 of 25). There were no early graft occlusions or amputations. There was one late graft occlusion. There were no late amputations. The reinfection rate was 22% (5 grafts). All reinfections occurred in patients operated upon for occlusive disease. Only one reinfection occurred in the rifampin-soaked graft group (11% versus 29%, P = NS). Reinfection tended to be lower in patients with aortoenteric fistulas and without abscess. Autogenous tissue coverage provided statistically significant protection against reinfection. There were no late deaths related to in situ graft infection. CONCLUSIONS: Patients treated with in situ graft replacement had an 8% mortality and 100% limb salvage rate. Reinfection rates were similar to those of extra-anatomic bypass, but a trend of lower reinfection rates with rifampin-impregnated grafts was apparent. Patients with aortoenteric fistula and without abscess appear to be well treated by the technique of in situ prosthetic grafting and autogenous tissue coverage.     

Rigid intraluminal prosthesis for replacement of thoracic and abdominal aorta

From December 1976 to April 1983, 55 patients underwent operations in which intraluminal ring grafts were used for replacement of thoracic and abdominal aortic aneurysms. Twenty-eight patients had dissections, and 11 had ascending aneurysms. There were 10 descending aneurysms; three of these were traumatic. There were two arch aneurysms, three abdominal aneurysms, and one thoracoabdominal aneurysm. The follow-up period was 78 months with a mean follow-up period of 24 months. There were six postoperative deaths and six late deaths. No evidence of complications of thrombosis, migration, erosion, or pseudoaneurysm resulting from the ring within the 78-month follow-up period was seen, and we conclude that this is a safe, reliable, quick method for replacement of the aorta in certain well-defined situations.     

Challenges of endovascular tube graft repair of thoracic aortic aneurysm: midterm follow-up and lessons learned

OBJECTIVES: Endovascular stent-graft repair has great potential in treatment of thoracic aortic aneurysms. This study analyzed a single center's experience with first-generation commercially produced thoracic stent grafts used to treat descending thoracic aortic aneurysms. METHODS: Over 58 months 84 patients underwent endovascular stent-graft repair of descending thoracic aortic aneurysms; 22 patients received the Gore TAG stent graft, and 62 patients received the Talent thoracic endovascular stent-graft system. Each patient was enrolled in one of three distinct US Food and Drug Administration trials at Mount Sinai Medical Center in accordance with strict inclusion and exclusion criteria, including suitability for open surgery, aneurysm anatomy, and presence of comorbid medical illness. Mean age of this cohort was 71 +/- 12 years. There were 54 men and 30 women, and 74 (88%) had three or more comorbid illnesses. Primary technical success was achieved in 76 patients (90%). Mean follow-up was 15 months (range, 0-52 months). RESULTS: Successful aneurysm exclusion was achieved in 69 patients (82%). Major procedure-related or device-related complications occurred in 32 patients (38%). There were six proximal attachment failures (8%), four distal attachment failures (6%), one intergraft failure (1%), two mechanical device failures (3%), five periprocedural deaths (6%), and five late aneurysm ruptures (6%). At 40 months, overall survival was 67% (+/-10%), and freedom from rupture or from type I or type III endoleak was 74% (+/-10%). CONCLUSION: While promising, this midterm experience with commercially available devices highlights the shortcomings of current stent-graft technology. Three significant advancements are required to fulfill the potential of this important treatment method: a stent graft with a durable proximal and distal fixation device, enhanced engineering to accommodate high thoracic aortic fatigue forces, and a mechanism to adapt to aortic arch and visceral segment branches to enable treatment of lesions that extend to or include these vessels.     

Endoluminal stent grafts in the management of infrarenal abdominal aortic aneurysms: a realistic assessment.

OBJECTIVES: transfemoral endoluminal aortic management (TEAM) is technically feasible in the treatment of infrarenal abdominal aortic aneurysms but its advantage over conventional repair is unproved. We report our initial experience, learning curve and technical difficulties encountered during the process of establishing this novel technique in our institute. MATERIAL AND METHODS: over a 3-year period 400 cases of abdominal aortic aneurysms were reviewed; only 58 cases (15%) were suitable for endovascular repair under our TEAM protocol and 36 (9%) were offered endovascular intervention. They were mainly high-risk patients (85% ASA III and IV) with a mean age of 72 years. Thirty-three bifurcated grafts, two straight tube grafts and one aorto mono-iliac graft were deployed. We oversized the graft by 15-20% to the diameter of the aortic neck and both common iliac arteries. RESULTS: two cases (6%-95% CI: 1-19%) had on-table conversion because of ruptured common iliac arteries. Peri-operatively there were two deaths from multi-organ failure. Transient renal failure occurred in two patients and three patients (9%) suffered a non-fatal myocardial infarction. Sixteen percent of patients had a groin wound problem. The mean hospital stay was 7 days. Five minor endoleaks (15%) were identified and sealed at 30 days. One secondary endoleak was identified at 18 months because of a patent juxta-renal lumbar artery. No secondary cuffs or extensions were used. Mean follow-up was 29 months and all grafts remained patent. The technical, clinical, continuous and secondary success rates were 78%, 91%, 89% and 91% respectively with TEAM. CONCLUSION: endovascular training, patient selection and learning curve impose an impact on the final outcome. Until a reliable hard point is reached so that endovascular repair could be exercised in routine practice, the use of TEAM must be questioned in high-risk patients, and should be performed under clinical trial conditions using strict selection criteria.     

Hybrid approach to thoracoabdominal aortic aneurysms in patients with prior aortic surgery

OBJECTIVE: The hybrid approach to the repair of thoracoabdominal aortic aneurysm (TAAA), consisting of visceral aortic debranching with retrograde revascularization of the splanchnic and renal arteries and aneurysm exclusion using stent grafts, has been previously described and may be considered particularly appealing in high-risk patients, especially those who have undergone prior aortic surgery. This study analyzed prospectively recorded data of a series of high-risk patients with prior aortic surgery who underwent hybrid TAAA repair at our institute and contrasted the outcomes with those of a similar group of patients who underwent conventional open TAAA repair. METHODS: Between 2001 and 2006, 13 patients (12 men) with a median age of 69.6 years (range, 35 to 82 years) underwent one-stage hybrid repair of TAAA (7 type I, 2 type II, 2 type IV, and 2 aneurysms of the visceral aortic patch). These patients, the hybrid group, had a history of aortic surgery (30.7% ascending, 30.7% descending, 46.1% abdominal aortic repair, and 15.4% redo TAAA) and were at high risk for open repair. The criteria used to define these patients as high risk and to indicate the need for hybrid treatment were American Society of Anesthesiologists (ASA) class 3 or 4 associated with a preoperative forced expiratory volume in 1 second (FEV1)<50%. In all cases, we accomplished partial or total visceral aortic debranching through (1) a previous visceral artery retrograde revascularization with synthetic grafts (single bypass, customized Y or bifurcated grafts), and (2) aortic endovascular repair with one of three different commercially produced stent grafts (Cook, W.L. Gore & Assoc, and Medtronic). We analyzed the results and compared the outcomes of the hybrid group with those of a similar group of 29 patients (25 men) with a median age 65.3 years (range, 58 to 79) selected from our overall series of 246 TAAA repairs between 1988 and 2005. These 29 patients, the conventionally treated group, were selected for having had aortic surgery (22% ascending, 38% descending, 42% abdominal aortic repair, and 10.3% redo TAAA), an ASA 3 or 4, a preoperative FEV1<50%, and a conventional open repair of TAAA (10 type I, 5 type II, 4 type III, 7 type IV, and 3 aneurysms of the visceral aortic patch). RESULTS: In the hybrid group, 32 visceral bypasses were completed and endovascular TAAA repair was successful in all cases. No intraoperative deaths occurred. Perioperative mortality was 23%, and morbidity was 30.8% (renal failure in 2, respiratory failure in 1, and delayed transient paraplegia in 1). At a median follow-up of 14.9 months (range, 11 days to 59.4 months), all grafts were patent at postoperative computed tomography angiography and no aneurysm-related deaths, endoleak, stent graft migration, or morbidity related to visceral revascularization had occurred. No conventionally treated patients died intraoperatively. Perioperative mortality was 17.2% and morbidity was 44.8% (respiratory failure in 7, coagulopathy in 1, renal failure in 2, and paraplegia in 3). At a median follow-up of 5.4 years (range, 1.7 to 7.9 years), no significant complications related to aortic repair occurred, except for three patients (10.3%) with asymptomatic dilatation of the visceral aortic patch<5 cm undergoing radiologic surveillance. CONCLUSION: Hybrid TAAA repair is technically feasible in selected cases. Perioperative morbidity and mortality were considerable in our subset of high-risk patients with prior aortic surgery, but no aneurysm-related or procedure-related complications were reported at mid-term follow-up. Hybrid TAAA repair did not lead to a significant improvement in outcomes compared with open TAAA repair in a similar group of patients. Larger series are required for valid statistical comparisons and longer follow-ups are necessary to evaluate the durability of hybrid repairs.     

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

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

Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization

OBJECTIVE: We review our ongoing experience with a transabdominal stent repair of complex thoracoabdominal aneurysms (Crawford type I, II, and III) with surgical revascularization of visceral and renal arteries. METHODS: A retrospective review was conducted of prospectively collected data from 29 consecutive patients who underwent an attempted visceral hybrid procedure between January 2002 and April 2005. Twenty-two patients were elective, four were urgent (symptomatic), and three were emergent (true rupture). The median patient age was 74 years (range, 37 to 81 years). The aneurysms were Crawford type I in 3, type II in 18, type III in 7, and type IV in 1. Previous aortic surgery had been performed in 13 (45%) of 29 and included aortic valve and root replacement in 3, TAA repair in 1, type I repair in 1), type IV repair in 3, type B dissection in 2, infrarenal aneurysm in 5, and right common iliac aneurysm in 1. Severe preoperative comorbidity was present in 23 (80%) of 29: chronic renal impairment in 5, severe chronic obstructive pulmonary disease in 6, myocardial disease in 11 at New York Heart Association grade II (6) and grade III (5), and Marfan's syndrome in 6. Twenty-six patients (90%) had a completed procedure. In two patients, myocardial instability prevented completion of the procedure despite extensive preoperative cardiac assessment, and in one, poor flow in the true lumen of a chronic type B dissection prevented anastomosis of the revascularization grafts. Exclusion of the full thoracoabdominal aorta was achieved in all 26 completed procedures and extended to include the iliac arteries in four, with revascularization of coeliac in 26, superior mesenteric artery in 26, left renal artery in 21, and right renal artery in 21). RESULTS: There was no paraplegia < or =30 days or during inpatient admission, and elective and urgent mortality was 13% (3/23). All of the patients with ruptured thoracoabdominal aneurysms died < or =30 days. Major complications included prolonged respiratory support (>5 days) in 9, inotropic support in 4, renal impairment requiring temporary support in 2 and not requiring support in 2, prolonged ileus in 2, resolved left hemispheric stroke in 1, and resection of an ischemic left colon in 1. Median blood loss was 3.9 liters (range, 1.2 to 13 liters). The median ischemia time was 15 minutes (range, 13 to 27 minutes) for the superior mesenteric and coeliac arteries and 15 minutes for the renal arteries (range, 13 to 21 minutes). The median hospital stay was 27 days (range, 16 to 84 days). Follow-up was a median of 8 months (range, 2 to 31 months), with 92 of 94 grafts patent. Six patients were found to have a type I endoleak. In four, this was a proximal leak, and stent extension in three reduced, but did not cure, the endoleak. One patient with a distal type I endoleak was successfully treated by embolization. Four type II endoleaks resolved without intervention, and one was treated by occlusion coiling of the origin of the left subclavian artery. A single late type III endoleak was found. CONCLUSION: Early results of visceral hybrid stent-grafts for types I, II, and III thoracoabdominal aneurysms are encouraging, with no paraplegia in this particularly high-risk group of patients. These results have encouraged us to perform the new procedure, in preference to open surgery, in Crawford type I, II, and III thoracoabdominal aortic aneurysms.     

Endovascular repair of lesions involving the descending thoracic aorta

BACKGROUND: Vascular lesions involving the thoracic aorta are often life-threatening conditions that carry significant morbidity and mortality with traditional open surgical repair. Preliminary results suggest that endovascular therapy is an effective and possibly advantageous treatment for diseases of the descending thoracic aorta. METHODS: Between October 2000 and May 2004, 50 consecutive patients underwent endovascular stent-grafting of lesions involving the descending thoracic aorta. Attempted stent-graft deployment was performed electively in 39 patients and emergently in 11. The pathology of electively treated aortic lesions included degenerative/atherosclerotic aneurysms (n = 24), pseudoaneurysms (n = 11), aortic dissections (n = 2), and penetrating ulcers (n = 2). Emergently treated aortic lesions were for acute rupture due to infectious (mycotic) aneurysms (n = 4), atherosclerotic/degenerative aneurysms (n = 3), acute type B dissections (n = 2), and acute transections (n = 2). Devices used include Talent (n = 45), AneuRx aortic cuffs (n = 2), custom-fabricated Gianturco-Dacron grafts (n = 2), and a modified Cook-Zenith abdominal aortic graft (n = 1). Follow-up was performed at 1-month, 6-months, 1-year, and annually thereafter. RESULTS: Primary technical success, defined as successful deployment and exclusion of the lesion without evidence of type I or type III endoleak, was achieved in 48 (96%) of 50 patients. In one patient, the procedure was terminated due to inability to access the iliac vessels. In another patient, a type III endoleak was observed at the completion of the primary procedure that required deployment of an additional stent-graft component 2 months later. Of the 49 patients who received endografts, seven underwent secondary procedures to correct endoleaks, with five of these seven requiring the deployment of additional endovascular stent-graft components. Major complications included four in-hospital deaths, with three of these occurring in patients treated emergently. Additionally, respiratory failure (n = 6), multisystem organ failure (n = 2), cerebrovascular accident (n = 2), retroperitoneal hematoma (n = 2), acute renal insufficiency (n = 1), and pulmonary embolus (n = 1) were also observed. The overall endoleak rate was 20%, with five primary (< or = 30 days) and five secondary (> 30 days) endoleaks observed. Five of the endoleaks were treated with the deployment of one or more additional endovascular stent-graft components. Two of the endoleaks were treated with endovascular balloon remolding. Mean follow-up was 271 days. There were no aneurysm ruptures or aneurysm-related deaths. CONCLUSIONS: Endovascular treatment of vascular lesions involving the descending thoracic aorta can be safely performed with low morbidity in high-risk patients. Endovascular repair may become an attractive alternative for the treatment of a wide range of pathology along this vascular territory.     

Experimental development of an endovascular graft for thoraco-abdominal aortic aneurysm repair

AIM: Current treatment of thoraco-abdominal aortic aneurysms is surgical. Despite significant advances in surgical technique and anesthetic management, significant morbidity and mortality remain associated with their repair. In compliance with principles of reducing postoperative morbidity, we developed a thoraco-abdominal endovascular graft in experimental models of type III and type IV thoraco-abdominal aortic aneurysm. This device had to preserve the vascularization of the visceral arteries while ensuring full aneurysmal exclusion. METHODS: Six implantations of the endovascular graft were performed. This graft was a modular system, made of: 1) a custom made main body containing 4 prosthetic visceral branches, 2) 4 self-expandable stent-grafts connecting prosthetic visceral branches with visceral arteries, 3) a custom made tubular endovascular graft connecting the main body with one of the iliac arteries. RESULTS: On angiographic controls, full aneurysmal exclusion was achieved while maintaining visceral artery perfusion. At the end of each procedure, the experimental model was opened. Macroscopic examination showed harmonious thoraco-abdominal endovascular graft deployments, without abnormal component constraint or kinking. There was no discordance between macroscopic and angiographic RESULTS: CONCLUSIONS: Our experimental work led to the development of a thoraco-abdominal endovascular graft, demonstrating feasibility of thoraco-abdominal aneurysm endoluminal treatment on an in vitro model close to the anatomical conditions observed in human pathology.     

Mycotic aneurysms of the suprarenal abdominal aorta: prolonged survival after in situ aortic and visceral reconstruction

Necrotizing infection of the arterial wall causes rupture and false ("mycotic") aneurysm formation, with a very poor prognosis if untreated. Cure can be achieved by surgical drainage and debridement, with restoration of arterial continuity through uncontaminated tissues. The dilemma of applying these principles to the treatment of mycotic aneurysms of the suprarenal aorta is that no remote or extraanatomic routes are available to maintain perfusion to the viscera. We report the first case of Klebsiella suprarenal mycotic aortic aneurysm successfully treated with in situ prosthetic reconstruction of the aorta and visceral arteries, and we have reviewed the 21 other suprarenal mycotic aortic aneurysms reported in the English-language literature. Repair was performed in 20 of the 22 cases, with in situ prosthetic reconstruction performed in 18. Prolonged survival has been achieved in 16 patients after in situ repair. No long-term survival has been reported after extraanatomic reconstruction of the aorta and visceral arteries in patients with such aneurysms. We conclude that in situ prosthetic reconstruction, accompanied by thorough drainage and debridement, prolonged parenteral antibiotic therapy, and permanent suppressive oral antibiotics, offers the best chance for survival in these patients.     

Endovascular Stent-Graft Repair of Mycotic Aneurysms of the Aorta: A Case Series with a 22-Month Follow-Up

Background  The purpose of the present study was to present a single-institution series of patients with mycotic aneurysms of the aorta treated with endovascular stent-graft technology, and to report the efficacy and short-term durability of this repair. Methods  A retrospective review of seven consecutive patients with mycotic aneurysms of the aorta treated with stent-graft between May 2006 and July 2007. Patients were diagnosed based on typical appearance of imaging together with a positive bacteriology culture or clinical evidence of infection. A bifurcated, aorto-uni-iliac (AUI) stent-graft and cuff were used in the endovascular repair after infection control. The follow-up protocol included regular clinical examination, hematologic tests, and computed tomography scans at 3, 6, 12, and 24 months. Results  Endovascular aneurysm repair (EVAR) was performed successfully in the seven patients (all men, median age 56 years), with complete exclusion of the aneurysms. Five of the patients had infrarenal aortic aneurysms, and the other two had descending thoracic aortic aneurysms. The median hospital stay was 22 days, with no hospital deaths. No paraplegia or other major complications occurred. The patients remained well, with no evidence of graft infection at a mean follow-up of 22.7 months (range: 17–26 months). A significant reduction in the diameter of the aneurysm sac was noted on computed tomography scans in all the patients at 1 year (mean: 6.5 mm; range: 3–40 mm). Conclusions  Endovascular stent-graft treatment represents an alternative treatment with acceptable short-term outcomes for patients with mycotic aneurysms of the aorta.     

Cryopreserved Arterial Allografts in the Treatment of Prosthetic Graft Infections

AIM: The purpose of this study was to evaluate the effectiveness of cryopreserved arterial allografts in the management of prosthetic graft infection. MATERIAL AND METHODS: Over a 5-year period 45 patients with infection of prosthetic vascular grafts were treated. There were 39 intra-abdominal infected grafts (group I) and six extra-abdominal infected grafts (group II). Treatment consisted of total graft removal and in situ or extra-anatomic implantation of cryopreserved arterial allografts. Six patients were operated on as an emergency. Four patients presented with aorto-enteric fistula. Follow-up ranged from 30 to 78 months. RESULTS: There were six in-hospital deaths and two additional patient deaths during follow-up, yielding an overall mortality rate of 18%. Six patients died due to complications directly related to infection or insertion of an allograft. Combined short and long-term mortality rate was much higher in patients operated on as an emergency (67%) compared to elective cases (11%). Patients with aorto-enteric fistula had the highest mortality rate (75%). Primary and secondary 3-year allograft patency rates for group I were 84 and 94%, respectively and for group II were 60 and 80%, respectively. CONCLUSIONS: Aortic allografts are useful in the treatment of infection of major vascular prosthetic grafts, except for patients with aorto-enteric fistula. Patients with infection of the prosthetic graft should be promptly assessed for graft removal, since results of elective surgery are much better than results of emergency procedures.