Editor's Choice – Treatment of Aortic Prosthesis Infections by Graft Removal and In Situ Replacement with Autologous Femoral Veins and Fascial Strengthening

Late Fate of Cryopreserved Arterial Allografts

OBJECTIVE

Initial enthusiasm for use of cryopreserved arterial allografts was subsequently tempered by suboptimal long-term outcome. Thrombosis, anastomotic pseudo-aneurysm, allograft disruption, aneurysmal degeneration, recurrent intestinal fistulization, and persistent infection are commonly reported in series with long-term follow-up. The authors reviewed their experience over the past 15 years with the use of cryopreserved arterial allografts as a vascular substitute for vascular prosthetic infection or for primary arterial infection, to investigate allograft-related complications.

MATERIAL AND METHODS

A retrospective analysis of prospectively collected data was conducted for 103 cryopreserved arterial allografts inserted in 96 patients between July 2000 and July 2015. There were 78 patients with infected vascular prosthesis (IVP), nine patients with an aorto-enteric fistula (AEF), and nine patients with primary arterial infection (PAI).

RESULTS

The in-hospital mortality was eight out of 78 (9%) IVP patients, three out of nine AEF patients, and zero out of nine PAI patients. Median follow-up was 49 months. Allograft-related re-interventions were necessary in 29% of the patients with IVP and four of the patients with AEF, but none of the patients with PAI. Five-year survival for the IVP, AEF, and PAI patients was 53%, 44%, and 90%, respectively.

CONCLUSION

This series highlights some shortcomings of cryopreserved arterial allografts in the long term, including suboptimal outcome-results and shortage of material. The authors discuss the allograft-related complications and suggest some tricks to minimize their risk.

Operative technique and morbidity of superficial femoral vein harvest

Background

The use of autologous superficial femoral veins (SFV) as an arterial or venous substitute represents a valuable technique in modern vascular surgery with versatile indications. The SFV autografts exhibit excellent control of infection and durable long-term results in terms of graft patency in prosthetic or arterial infections. In cases of elective use of the SFV, duplex ultrasound evaluation of the deep leg vein system should be implemented to confirm the patency of the profunda femoris vein.

Material and methods

The SFV can be harvested distal to the adductor hiatus with a proximal portion of the popliteal vein but should not exceed the level of the knee joint. Formation of a stump of the proximal SFV must be avoided. Simultaneous harvesting of the ipsilateral greater saphenous vein should be avoided to reduce the risk of significant chronic edema.

Results

Early postoperative swelling of the donor leg can be expected but resolves spontaneously in most cases. Chronic mild edema of the leg with a possible indication for compression therapy may occur in up to 20 % of cases but severe complications are very rare if the anatomical borders for vein harvesting are respected. Temporary therapeutic anticoagulation after vein harvest is subject to individual decision making.

Conclusion

Duplex ultrasound is a reliable tool to assess the residual deep and superficial venous system in the long term. Excellent graft function and the tolerable adverse effects of vein harvest on the donor leg justify the use of the SFV in arterial and venous vascular surgery if indicated.

Late Stent Graft Infection after the Emergency Endovascular Repair of a Secondary Iliac Artery-Enteric Fistula Treated with Graft Removal and In Situ Aortic Reconstruction Using Femoral Veins

An arterioenteric fistula is a devastating and life-threatening condition that requires urgent treatment. Less-invasive endovascular treatment has emerged as an alternative to conventional open repair, but postoperative graft infection remains a major concern. We herein report a case of late stent graft infection after emergency endovascular repair of a secondary iliac artery-enteric fistula. The patient was a 63-year-old male who presented with a fever, who had undergone successful endovascular stent grafting for a secondary common iliac artery-enteric fistula 29 months prior. The diagnosis of a stent graft infection was confirmed via computed tomography. He underwent graft removal and in situ reconstruction with femoral vein grafts. At 6-month follow-up, the patient is in a good general condition without any symptoms.