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Ascione M, Dajci A, Cangiano R, Marzano A, Molinari A, Miceli F, Di Girolamo A, Leanza C, Oliva A, Di Marzo L, Mansour W. Open Surgical Conversion of Popliteal Endograft Infection: Case Reports and Literature Review. Biomedicines 2024; 12:1855. [PMID: 39200319 PMCID: PMC11351597 DOI: 10.3390/biomedicines12081855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Revised: 08/11/2024] [Accepted: 08/13/2024] [Indexed: 09/02/2024] Open
Abstract
BACKGROUND Endovascular treatment of popliteal aneurysms (PA) has increased in the last few years, quickly becoming the main treatment performed in many vascular centers, based on the acceptable and promising outcomes reported in the literature. However, endograft infections after endovascular popliteal aneurysm repair (EPAR) are the most dangerous complications to occur as they involve serious local compromise and usually require open surgical conversion and device explantation to preserve the affected extremity. CASE REPORT We report two patients who were admitted to the emergency room of our hospital for pain and edema in the lower leg. Both patients had undergone exclusion of a ruptured PA a few years before by endovascular graft. CTA testing showed a significant volume of fluid-corpuscular collection related to perianeurysmal abscess collection in both cases. Blood cultures and drained material cultures were positive for Staphylococcus capitis in the first case and S. aureus in the second. Prophylactic antibiotics were administered for 10 days, then patients underwent an open surgical conversion with the complete explantation of endovascular material and a femoro-popliteal bypass using an autologous vein in the first case and a biological bovine pericardium prosthesis in the second case. The infective department of our hospital had defined a discharged specific antibiotic therapy for each patient, based on intraoperative microbiological samples. Furthermore, we have examined the literature and found six more cases described in case report articles that refer to popliteal graft infections by different microorganisms, mostly presenting acute limb ischemia as the first symptom and suggesting endograft explantation with open conversion and autologous vein bypass as the commonest therapeutic choice. CONCLUSIONS The open surgical conversion of popliteal endograft infection is the best strategy to manage peripheral infection after an endovascular popliteal aneurysm repair procedure.
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Affiliation(s)
- Marta Ascione
- Vascular and Endovascular Surgery Division, Department of General Surgery and Surgical Specialties, Policlinico Umberto I, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (A.D.); (R.C.); (A.M.); (A.M.); (F.M.); (A.D.G.); (L.D.M.)
| | - Ada Dajci
- Vascular and Endovascular Surgery Division, Department of General Surgery and Surgical Specialties, Policlinico Umberto I, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (A.D.); (R.C.); (A.M.); (A.M.); (F.M.); (A.D.G.); (L.D.M.)
| | - Rocco Cangiano
- Vascular and Endovascular Surgery Division, Department of General Surgery and Surgical Specialties, Policlinico Umberto I, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (A.D.); (R.C.); (A.M.); (A.M.); (F.M.); (A.D.G.); (L.D.M.)
| | - Antonio Marzano
- Vascular and Endovascular Surgery Division, Department of General Surgery and Surgical Specialties, Policlinico Umberto I, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (A.D.); (R.C.); (A.M.); (A.M.); (F.M.); (A.D.G.); (L.D.M.)
| | - Andrea Molinari
- Vascular and Endovascular Surgery Division, Department of General Surgery and Surgical Specialties, Policlinico Umberto I, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (A.D.); (R.C.); (A.M.); (A.M.); (F.M.); (A.D.G.); (L.D.M.)
| | - Francesca Miceli
- Vascular and Endovascular Surgery Division, Department of General Surgery and Surgical Specialties, Policlinico Umberto I, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (A.D.); (R.C.); (A.M.); (A.M.); (F.M.); (A.D.G.); (L.D.M.)
| | - Alessia Di Girolamo
- Vascular and Endovascular Surgery Division, Department of General Surgery and Surgical Specialties, Policlinico Umberto I, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (A.D.); (R.C.); (A.M.); (A.M.); (F.M.); (A.D.G.); (L.D.M.)
| | - Cristiana Leanza
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy; (C.L.); (A.O.)
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy; (C.L.); (A.O.)
| | - Luca Di Marzo
- Vascular and Endovascular Surgery Division, Department of General Surgery and Surgical Specialties, Policlinico Umberto I, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (A.D.); (R.C.); (A.M.); (A.M.); (F.M.); (A.D.G.); (L.D.M.)
| | - Wassim Mansour
- Vascular and Endovascular Surgery Division, Department of General Surgery and Surgical Specialties, Policlinico Umberto I, “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (A.D.); (R.C.); (A.M.); (A.M.); (F.M.); (A.D.G.); (L.D.M.)
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Hsu JF, Lentz RB, Ziegler KR, Wong AK. Use of a bovine pericardial patch angioplasty for completion of a complicated end to side anastomosis of a recipient vessel in the free flap reconstruction of a radiated wound: A case report. Microsurgery 2023; 43:161-165. [PMID: 36571830 PMCID: PMC10108141 DOI: 10.1002/micr.31000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 11/13/2022] [Accepted: 12/14/2022] [Indexed: 12/27/2022]
Abstract
Soft tissue sarcomas treated by extensive surgical resection and adjuvant radiation can lead to large tissue deficits that require free flap repair. Significant radiation can further compromise vessels necessitating novel therapeutic approaches. We describe an 82-year-old man who presented with a posterior thigh sarcoma and underwent wide local tumor resection and immediate reconstruction with a microvascular free flap. Due to radiated recipient vessels, this case required bovine patch angioplasty as a conduit for end to side anastomosis. Initial resection and pathology revealed a large myxofibrosarcoma. Wide local resection and radiotherapy resulted in a large irradiated soft tissue defect of 26 x 15 x 4 cm with exposed, radiation damaged neurovascular structures, and a lack of available regional flap options. The planned free flap, a 30 x 8 cm skin island from the left latissimus dorsi muscle with end-to-side anastomosis to the popliteal artery was complicated by friability of the vessel wall and insufficient perfusion. Given the extent of resection and radiation, there were no alternative recipient vessels present within the field. A bovine pericardial patch angioplasty of 2.5 cm in length was performed to the diseased popliteal vessel and an end to side anastomosis was successfully performed between the thoracodorsal artery and the patch. Improved reperfusion of the free flap was noted immediately following anastomosis indicating completion of the anastomosis of our complicated recipient vessel. During the uncomplicated postoperative course, the flap had good perfusion with Doppler signals present, and incision sites intact at discharge from acute hospitalization. Recurrent sarcomas that have undergone extensive resection and radiotherapy pose significant reconstructive challenges. For defects that require free tissue reconstruction when there are limited options for healthy, recipient vessels, bovine pericardial patch angioplasty may act as a robust conduit for diseased vessels.
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Affiliation(s)
- Jerry F Hsu
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, California, USA.,Division of Plastic Surgery, City of Hope National Medical Center, Duarte, California, USA
| | - Rachel B Lentz
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, California, USA.,Division of Plastic Surgery, University of Washington, Seattle, Washington, USA
| | - Kenneth R Ziegler
- Division of Vascular Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Alex K Wong
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, California, USA.,Division of Plastic Surgery, City of Hope National Medical Center, Duarte, California, USA
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Computed Tomography Angiography and B-Mode Ultrasonography under Artificial Intelligence Plaque Segmentation Algorithm in the Perforator Localization for Preparation of Free Anterolateral Femoral Flap. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:4764177. [PMID: 36247860 PMCID: PMC9534661 DOI: 10.1155/2022/4764177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/15/2022] [Accepted: 08/05/2022] [Indexed: 01/26/2023]
Abstract
This research was aimed to investigate the accuracy of U-shaped network (UNet)-based computed tomography angiography (CTA) and B-mode ultrasonography (US) in the perforator localization of free anterolateral thigh flap (ALTF). Based on UNet, a fusion of deep supervision mechanism, squeeze-and-excitation module, and attention mechanism was introduced to optimize the algorithm. Then, a CTA segmentation model, DA-UNet, was established. The segmentation performance of DA-UNet and other algorithms was compared under the same conditions. 30 patients who were planned to receive ALTF surgery were selected as the research objects. According to different preoperative localization methods, they were divided into group A (CTA) and group B (B-mode US), 15 cases in each group. Combined with the actual situation during surgery, the diagnostic accordance rate, sensitivity (Sen), specificity, and the distance between the perforator location and the actual location were compared between the two groups. The Dice coefficient, Jaccard index, Sen, the area under curve (AUC), and average Hausdorff distance (AVD) of the DA-UNet segmentation algorithm were 80.70%, 69.97%, 77.56%, 0.887, and 2.48, respectively. These results were significantly better than those of other algorithms (P < 0.05). In group A, the diagnostic accordance rate, Sen, and specificity of patients were 96.55%, 90.52%, and 73.58%, respectively, which were higher than 91.53%, 81.36%, and 15.60% of patients in group B significantly (P < 0.05). There was no statistical difference in the distance between the perforator location and the actual location (P > 0.05). It showed that the accuracy of CTA under the UNet-based DA-UNet segmentation model in the perforator localization of ALTF was better than that of B-mode US. Thus, a reference could be provided for the preparation of free ALTF and its clinical application.
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Stöwe I, Pissarek J, Moosmann P, Pröhl A, Pantermehl S, Bielenstein J, Radenkovic M, Jung O, Najman S, Alkildani S, Barbeck M. Ex Vivo and In Vivo Analysis of a Novel Porcine Aortic Patch for Vascular Reconstruction. Int J Mol Sci 2021; 22:7623. [PMID: 34299243 PMCID: PMC8303394 DOI: 10.3390/ijms22147623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 06/25/2021] [Accepted: 07/13/2021] [Indexed: 01/12/2023] Open
Abstract
(1) Background: The aim of the present study was the biocompatibility analysis of a novel xenogeneic vascular graft material (PAP) based on native collagen won from porcine aorta using the subcutaneous implantation model up to 120 days post implantationem. As a control, an already commercially available collagen-based vessel graft (XenoSure®) based on bovine pericardium was used. Another focus was to analyze the (ultra-) structure and the purification effort. (2) Methods: Established methodologies such as the histological material analysis and the conduct of the subcutaneous implantation model in Wistar rats were applied. Moreover, established methods combining histological, immunohistochemical, and histomorphometrical procedures were applied to analyze the tissue reactions to the vessel graft materials, including the induction of pro- and anti-inflammatory macrophages to test the immune response. (3) Results: The results showed that the PAP implants induced a special cellular infiltration and host tissue integration based on its three different parts based on the different layers of the donor tissue. Thereby, these material parts induced a vascularization pattern that branches to all parts of the graft and altogether a balanced immune tissue reaction in contrast to the control material. (4) Conclusions: PAP implants seemed to be advantageous in many aspects: (i) cellular infiltration and host tissue integration, (ii) vascularization pattern that branches to all parts of the graft, and (iii) balanced immune tissue reaction that can result in less scar tissue and enhanced integrative healing patterns. Moreover, the unique trans-implant vascularization can provide unprecedented anti-infection properties that can avoid material-related bacterial infections.
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Affiliation(s)
- Ignacio Stöwe
- Helios Clinic Emil-von-Behring, Department of Vascular and Endovascular Surgery, 14165 Berlin, Germany;
- Clinic and Policlinic for Dermatology and Venereology, University Medical Center Rostock, 18057 Rostock, Germany; (S.P.); (J.B.); (O.J.)
| | - Jens Pissarek
- biotrics bioimplants AG, 12109 Berlin, Germany; (J.P.); (P.M.)
| | - Pia Moosmann
- biotrics bioimplants AG, 12109 Berlin, Germany; (J.P.); (P.M.)
| | - Annica Pröhl
- BerlinAnalytix GmbH, 12109 Berlin, Germany; (A.P.); (S.A.)
| | - Sven Pantermehl
- Clinic and Policlinic for Dermatology and Venereology, University Medical Center Rostock, 18057 Rostock, Germany; (S.P.); (J.B.); (O.J.)
| | - James Bielenstein
- Clinic and Policlinic for Dermatology and Venereology, University Medical Center Rostock, 18057 Rostock, Germany; (S.P.); (J.B.); (O.J.)
| | - Milena Radenkovic
- Scientific Research Center for Biomedicine, Department for Cell and Tissue Engineering, Faculty of Medicine, University of Niš, 18000 Niš, Serbia; (M.R.); (S.N.)
| | - Ole Jung
- Clinic and Policlinic for Dermatology and Venereology, University Medical Center Rostock, 18057 Rostock, Germany; (S.P.); (J.B.); (O.J.)
| | - Stevo Najman
- Scientific Research Center for Biomedicine, Department for Cell and Tissue Engineering, Faculty of Medicine, University of Niš, 18000 Niš, Serbia; (M.R.); (S.N.)
- Department of Biology and Human Genetics, Faculty of Medicine, University of Niš, 18000 Niš, Serbia
| | - Said Alkildani
- BerlinAnalytix GmbH, 12109 Berlin, Germany; (A.P.); (S.A.)
| | - Mike Barbeck
- Department of Ceramic Materials, Chair of Advanced Ceramic Materials, Institute for Materials Science and Technologies, Technical University Berlin, 10623 Berlin, Germany
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Carotid Endarterectomy with Stent Graft Removal and End to End Bypass in the Treatment of In-Stent Occlusion after Endovascular Therapy of Carotid Gunshot Injury. Ann Vasc Surg 2021; 76:591-596. [PMID: 33951522 DOI: 10.1016/j.avsg.2021.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/11/2021] [Accepted: 04/04/2021] [Indexed: 11/20/2022]
Abstract
Carotid jugular fistula and pseudoaneurysm are easy to form after gunshot injury of carotid artery. Endovascular therapy, such as stent graft implantation, can successfully block the fistula and pseudoaneurysm cavity. However, the possibility of in-stent restenosis or occlusion will lead to treatment failure. The authors describe the case of a 30-year-old man with carotid jugular fistula and pseudoaneurysm after gunshot injury of left carotid artery who had received stent graft placement. However, two years after stent graft, the stenosis of proximal carotid artery near stent was found and gradually aggravated. During the follow-up, transient amaurosis of his left eye occurred intermittently and in-stent occlusion and severe stenosis of proximal carotid artery were found by computed tomography angiography (CTA) in our center. Carotid endarterectomy (CEA)with stent graft removal and end to end bypass using vascular graft was performed to reconstruct the blood flow of left carotid artery. To the extent of the authors' knowledge, this case illustrates a rare CEA and vascular graft bypass in the treatment of in-stent occlusion following the gunshot injury to the carotid artery. The successful treatment of this rare case provides an option to deal with this kind of tricky problem.
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