In situ rifampin-soaked grafts with omental coverage and antibiotic suppression are durable with low reinfection rates in patients with aortic graft enteric erosion or fistula

Contemporary outcomes for arterial reconstruction with non-saphenous vein cryo-preserved conduits

OBJECTIVE

Cryopreserved (CP) products are utilized during challenging cases when autogenous or prosthetic conduit use is not feasible. Despite decades of experience with cadaveric greater saphenous vein (GSV), there is limited available data regarding the outcomes and patency of other CP products, specifically arterial and deep venous grafts. This study was designed to evaluate outcomes of non-GSV CP conduits in patients undergoing urgent, emergent, and elective arterial reconstruction at our institution. We hypothesized that non-GSV CP allografts have adequate patency and outcomes and are therefore a feasible alternative to GSV in settings where autologous graft is unavailable or prosthetic grafts are contraindicated.

METHODS

This study was approved by the Institutional Review Board at our institution. We retrospectively reviewed charts of patients undergoing arterial reconstructions using CP conduits from 2010 to 2022. Data collected included demographics, comorbidities, smoking status, indications for surgery, indication for CP conduit use, anatomic reconstruction, urgency of procedure, and blood loss. Time-to-event outcomes included primary and secondary graft patency rates, follow-up amputations, and mortality; other complications included follow-up infection/reinfection and 30-day complications, including return to the operating room and perioperative mortality. Time-to-event analyses were evaluated using product-limit survival estimates.

RESULTS

Of 96 identified patients receiving CP conduits, 56 patients received non-GSV conduits for 66 arterial reconstructions. The most common type of non-GSV CP product used was femoral artery (31 patients), followed by aorto-iliac artery (22 patients), and femoral vein (19 patients), with some patients receiving more than one reconstruction or CP product. Patients were mostly male (75%), with a mean age of 63.1 years and a mean body mass index of 26.7 kg/m2. Indications for CP conduit use included infection in 53 patients, hostile environment in 36 patients, contaminated field in 30 patients, tissue coverage concerns in 30 patients, inadequate conduit in nine patients, and patient preference in one patient. Notably, multiple patients had more than one indication. Most surgeries (95%) were performed in urgent or emergent settings. Supra-inguinal reconstructions were most common (53%), followed by extra-anatomic bypasses (47%). Thirty-day mortality occurred in 10 patients (19%). Fifteen patients (27%) required return to the operating room for indications related to the vascular reconstructions, with 10 (18%) cases being unplanned and five (9%) cases planned/staged. Overall survival at 6, 12, and 24 months was 80%, 68%, and 59%, respectively. Primary patency at 6, 12, and 24 months was 86%, 70%, and 62%, respectively. Amputation freedom at 6 months, 12 months, and 24 months was 98%, 95%, and 86%, respectively for non-traumatic indications.

CONCLUSIONS

Non-GSV CP products may be used in complex arterial reconstructions when autogenous or prosthetic options are not feasible or available.

Iliac artery-enteric fistulas following failed pancreatic transplant

Arterial-enteric fistulas occur from a multitude of causes, especially following surgical manipulation of vasculature. The development of an iliac artery-enteric fistula (IEF) occurs rarely in patients with failed pancreatic transplants. IEFs warrant urgent intervention due to the high mortality from hemorrhagic and septic shock. The diagnosis can be delayed by a lack of suspicion, the low sensitivity of diagnostic tests, and the nonspecific signs of fistulas on computed tomography. The management of IEFs is adapted from guidelines for arterial-enteric fistulas of other causes, with little consensus on ideal vascular reconstruction and postoperative antimicrobial management. The outcomes are limited to the short-term results from case reports and case series. We report two cases of IEFs in patients with a history of simultaneous pancreatic kidney transplant. Our patients underwent successful resolution of gastrointestinal bleeding and sepsis, with definitive management of fistula resection and interposition iliac artery bypass. The index of suspicion for IEFs should be high, and they should be considered as a source of anemia or gastrointestinal bleeding of an unknown source in patients with failed pancreatic transplant. Definitive management should be pursued in patients who can tolerate fistula resection, allograft explant, and arterial reconstruction.

Revascularization and Digestive Tract Repair in Secondary Aortoenteric Fistula Using a Single-Center in Situ Revascularization Strategy

BACKGROUND

Information regarding optimal revascularization and digestive tract repair in secondary aortoenteric fistula (sAEF) remains unclear. Thus, reporting treatment outcomes and presenting comprehensive patient details through a structured treatment approach are necessary to establish a treatment strategy for this rare, complex, and fatal condition.

METHODS

We performed a single-center retrospective review of consecutive sAEF managed based on our in situ revascularization and intestinal repair strategy. The primary endpoint of this study was all-cause mortality, and secondary endpoints were the incidence of in-hospital complications and midterm reinfections.

RESULTS

Between 2007 and 2020, 16 patients with sAEF, including 13 men (81%), underwent in situ revascularization and digestive tract repair. The median follow-up duration for all participants was 36 (interquartile range, 6-62) months. Among the participants, 81% (n = 13), 13% (n = 2), and 6% (n = 1) underwent aortic reconstruction with rifampin-soaked grafts, unsoaked Dacron grafts, and femoral veins, respectively. The duodenum was the most commonly involved site in enteric pathology (88%; n = 14), and 57% (n = 8) of duodenal breaks were repaired by a simple closure. Duodenum's second part-jejunum anastomosis was performed in 43% of patients (n = 6), and 19% of the patients (n = 3) died perioperatively. In-hospital complications occurred in 88% patients (n = 14), and the most frequent complication was gastrointestinal. Finally, 81% patients (n = 13) were discharged home. Oral antibiotics were administered for a median duration of 5.7 months postoperatively; subsequently, the participants were followed up carefully. Reinfection was detected in 6% of the patients (n = 1) who underwent reoperation without any complications. The 1-year and 3-year overall survival rates of participants were 75% (n = 12) and 75% (n = 9), respectively, and no sAEF-related deaths occurred, except perioperative death.

CONCLUSIONS

Surgical intervention with contemporary management based on our vascular strategy and digestive tract procedure may be a durable treatment for sAEF.

Early and late outcomes of surgical repair of mycotic aortic aneurysms: A 30-year experience

OBJECTIVE

Mycotic aortic aneurysm and its associated complications are often catastrophic. In this study, we examined the early and late outcomes of surgical repair of mycotic aortic aneurysm at our center over the last 3 decades.

METHODS

We retrospectively reviewed our prospectively maintained aortic surgery database with supplemental adjudication of medical records. Aortic infection was confirmed through clinical, radiological, intraoperative, pathological, and treatment evidence.

RESULTS

Seventy-five patients (median age, 68 years; interquartile range, 62-74) who underwent surgical repair of a mycotic aortic aneurysm between 1992 and 2021 were included. Almost all patients (n = 72; 96%) presented with symptoms, including 26 patients (35%) with rupture, and many underwent urgent or emergency repair (n = 64; 85%). Sixty-one patients underwent open repair, and 14 patients underwent hybrid or endovascular repair. Infection-specific adjunct techniques included rifampin-soaked grafts (n = 16), omental pedicle flaps (n = 21), and antibiotic irrigation catheters (n = 8). There were 15 early deaths (20%), including 10 of the 26 patients (38%) who presented with rupture; however, persistent stroke, paraplegia or paraparesis, and renal failure necessitating dialysis were uncommon (each <5%). Almost all early survivors (52/60; 87%) were discharged with long-term antibiotic therapy. Estimated survival at 2, 6, and 10 years was 55.7% ± 5.8%, 39.0% ± 5.7%, and 26.9% ± 5.5%, respectively.

CONCLUSIONS

A substantial proportion of patients with mycotic aortic aneurysm present with rupture and generally require urgent or emergency repair. Operative mortality and complications are common, especially for patients who present with rupture, and late survival is poor.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Aortic Vascular Graft and Endograft Infection-Patient Outcome Cannot Be Determined Based on Pre-Operative Characteristics

Vascular graft/endograft infection (VGEI) is a serious complication after aortic surgery. This study investigates VGEI and patient characteristics, PET/CT quantification before surgical or conservative management of VGEI and post-intervention outcomes in order to identify patients who might benefit from such a procedure. PET standard uptake values (SUV) were quantitatively assessed and compared to a non-VGEI cohort. The primary endpoints were in-hospital mortality and aortic reintervention-free survival at six months. Ninety-three patients (75% male, 65 ± 10 years, 82% operated) were included. The initial operation was mainly for aneurysm (67.7%: 31% EVAR, 12% TEVAR, 57% open aortic repair). Thirty-two patients presented with fistulae. PET SUVTLR (target-to-liver ratio) showed 94% sensitivity and 89% specificity. Replacement included silver-coated Dacron (21.3%), pericardium (61.3%) and femoral vein (17.3%), yet the material did not influence the overall survival (p = 0.745). In-hospital mortality did not differ between operative and conservative treatment (19.7% vs. 17.6%, p = 0.84). At six months, 50% of the operated cohort survived without aortic reintervention. Short- and midterm morbidity and mortality remained high after aortic graft removal. Neither preoperative characteristics nor the material used for reconstruction influenced the overall survival, and, with limitations, both the in-hospital and midterm survival were similar between the surgically and conservatively managed patients.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Brazilian Society for Angiology and Vascular Surgery guidelines on abdominal aortic aneurysm

The Brazilian Society of Angiology and Vascular Surgery, through the Guidelines Project, presents new Abdominal Aortic Aneurysm Guidelines, on the subject of care for abdominal aortic aneurysm patients. Its development prioritized descriptive guidelines, using the EMBASE, LILACS, and PubMed databases. References include randomized controlled trials, systematic reviews, meta-analyses, and cohort studies. Quality of evidence was evaluated by a pair of coordinators, aided by the RoB 2 Cochrane tool and the Newcastle Ottawa Scale forms. The subjects include juxtarenal aneurysms, infected aneurysms, and new therapeutic techniques, especially endovascular procedures. The current version of the guidelines include important recommendations for the primary topics involving diagnosis, treatment, and follow-up for abdominal aortic aneurysm patients, providing an objective guide for medical practice, based on scientific evidence and widely available throughout Brazil.

Silver acetate and Triclosan Antimicrobial Graft Evaluation for surgical Repair of aortic disease (STAGER Study)

BACKGROUND

The aim of this study was to assess perioperative and late performance of a silver acetate and triclosan impregnated antimicrobial vascular graft (Intergard Synergy, Intervascular SAS, La Ciotat, France) during open surgical repair of abdominal aortic aneurysms (AAA), and to compare it with standard polyester grafts ones.

METHODS

This retrospective single-centre study (STAGER Study, clinicaltrials.gov: NCT04557254) included patients undergone non-infectious AAA surgical repair between 2012 and 2019, divided into two groups according to the implanted aortic prosthesis: standard polyester graft (PolyG) and silver-triclosan graft (SynG). Early primary endpoints were 30-day mortality, major adverse events (MAEs), and reintervention rates; late primary endpoints were overall and aortic-related survival, reintervention-free survival, and graft infection rate at a mean follow-up (FU) of 49.4±26.8 months.

RESULTS

Five hundred forty-seven patients were included [PolyG 49%, and SynG 51%]. Both groups were substantially homogeneous in risk factors and demographics. Two patients died within 30 days. In-hospital MAE rate [PolyG 14.2% vs. SynG 10.7%; P=.248] and 30-day reintervention rate were not significantly different [PolyG 2.6% vs. SynG 1.4%; P=.374]. At 5 years, overall survival in the PolyG and SynG groups were 85% and 84%, respectively. Reintervention-free survival was 82% for both groups. Aortic-related survival was 95% and 96%, respectively. Graft infection was observed in 8 (3.3%) PolyG patients and 5 (1.8%) SynG patients.

CONCLUSIONS

Silver acetate and triclosan impregnated grafts demonstrated good early and mid-term results, being considered safe and durable for AAA open repair. Similar graft infection and related death rates were observed compared to polyester standard grafts, supporting non-superiority of one graft over the other.

Paracolic Gutter Routing: A Novel Retroperitoneal Extra-Anatomical Repair for Infected Aorto-Iliac Axis

OBJECTIVE

We describe and analyze outcomes of a novel extra-anatomical paracolic gutter routing technique for surgical repair of aorto-iliac infections.

METHODS

A double-center, observational, cohort study of all consecutive patients with aorto-iliac infections treated using extra-anatomical paracolic gutter technique. Between May 2015 and December 2022, six patients with aorto-iliac infections were treated with the paracolic gutter routing technique. Cases were identified retrospectively in an institutional database, and data were retrieved from surgical records, imaging studies, and follow-up records.

RESULTS

Aorto-bifemoral vascular reconstructions were performed using this technique in six patients. During mean follow-up of 52 ± 44 months, there was one case of graft thrombosis (17%) with subsequent successful thrombectomy. Primary and secondary graft patency rates were 83% and 100%, respectively. There was one mortality (17%) due to candida sepsis. All graft prostheses were patent at last follow-up.

CONCLUSIONS

The paracolic gutter technique is a useful technique in patients with extensive aorto-iliac infections, arteriovenous and iliac-ureteric fistulas, or at a high risk of vascular graft infection and is associated with favorable reinfection and patency rates.

Performance of the BioIntegral Bovine Pericardial Graft in Vascular Infections: VASCular No-REact Graft Against INfection Study

BACKGROUND

Vascular graft and endograft infections (VGEI) and native vessel infections (NVI) remain considerable challenges in vascular surgery, leading to high mortality and morbidity rates. Although in situ reconstruction is the preferred treatment, the material of choice is still a source of debate. Autologous veins are considered the first choice; however, xenografts may be an acceptable alternative. The performance of a biomodified bovine pericardial graft is assessed when implemented in an infected vascular area.

METHODS

This is a prospective multicenter cohort study. Patients who underwent reconstruction for VGEI or NVI with a biomodified bovine pericardial bifurcated or straight tube graft were included from December 2017 until June 2021. The primary outcome measure was reinfection at mid-term follow-up. Secondary outcome measures included mortality, patency, and amputation rate.

RESULTS

Thirty-four patients with vascular infections were included, of which 23 (68%) had an infected Dacron prosthesis after primary open repair and 8 (24%) had an infected endovascular graft. The remaining 3 (9%) had infected native vessels. At secondary repair, 3 (7%) patients had an in situ aortic tube reconstruction, 29 (66%) had an aortic bifurcated reconstruction, and 2 (5%) had an iliac-femoral reconstruction. At 1-year follow-up after the BioIntegral bovine pericardial graft reconstruction, the reinfection rate was 9%. The 1-year infection-related and procedure-related mortality rate was 16%. The occlusion rate was 6% and in total 3 patients underwent a lower limb amputation during the 1-year follow-up period.

CONCLUSIONS

In situ reconstruction as treatment of (endo)graft and native vessel infections remains a challenge and reinfection looms as a potential consequence. In cases where time is of essence or when autologous venous repair is not feasible, a swift available solution is needed. The BioIntegral biomodified bovine pericardial graft may be an option as it shows reasonable results in terms of reinfection, in aortic tube and bifurcated grafts.

Feasibility and outcome of partial open surgical fenestrated stent graft explantation, radical debridement, and in situ reconstruction for late graft infection

Aortic stent graft infection is a rare, but potentially lethal, complication of endovascular aortic aneurysm repair. Definitive treatment is complete stent graft explanation with in-line or extra-anatomical reconstruction. However, several factors can render such an operation unsafe, including the patient's overall fitness for surgery and partial incorporation of graft with a resulting robust inflammatory process, especially around the visceral vessels. We present the case of a 74-year-old man with a history of an infected fenestrated stent graft that was managed with partial explantation, wide debridement, and in situ reconstruction using a rifampin-soaked graft and a 360° omental wrap with good results.

Who needs their descending thoracic aorta anyway? Extra-anatomic bypass for aorto-bronchial fistula after TEVAR

BACKGROUND

Aortobronchial fistula after TEVAR remains a vexing clinical problem associated with high mortality. Although a combination of endovascular and open surgical strategies have been reported in managing this pathology, there is as yet no definitive treatment algorithm that can be used for all patients. We discuss our approach to an aortobronchial fistula associated with an overtly infected aortic endograft.

CASE PRESENTATION

A 49-year-old female sustained a traumatic aortic transection 14 years prior, managed by an endovascular stent-graft. Due to persistent endoleak, she underwent open replacement of her descending thoracic aorta 4 years later. Ten years after her open aortic surgery, the patient presented with hemoptysis, and a pseudoaneurysm at her distal aortic suture line was identified on computed tomography, whereupon she underwent placement of an endograft. Eight weeks later, she presented with dyspnea, recurrent hemoptysis, malaise and fever, with clinical and radiographic evidence of an aortobronchial communication and an infected aortic stent-graft. The patient underwent management via a two-stage open surgical approach, constituting an extra-anatomic bypass from her ascending aorta to distal descending aorta and subsequent radical excision of her descending aorta with all associated infected prosthetic material and repair of the airway.

CONCLUSION

Aortobronchial fistula after TEVAR represents a challenging complex clinical scenario. Extra-anatomic aortic bypass followed by radical debridement of all contaminated tissue may provide the best option for durable longer-term outcomes.

Strategies and outcomes of different methods for treating abdominal aortic stent graft infection

Objective

To report the strategies and short-term results of different treatment methods for abdominal aortic stent graft infection.

Methods

Six consecutive patients (5 males and 1 female; mean age: 64 years; age range: 49-79 years) received surgical treatment for stent graft infection from November 2021 to December 2022. All patients underwent endovascular aortic repair (EVAR) for abdominal aortic and iliac artery disease, subsequently developed graft infection and then received corresponding surgical treatment with different materials (artificial blood vessel, bovine pericardium, autologous great saphenous vein) in our department. The outcomes were analysed.

Results

Immediate technical success was achieved intraoperatively in all six patients. The 30-day mortality rate was 0%. During a mean follow-up of 4 months (range, 3-13 months), one patient underwent a second operation due to vascular anastomotic haemorrhage and underwent bilateral limb amputations due to ischaemia. All patients survived.

Conclusions

In the short term, the different materils and methods used to treat aortic stent graft infection achieved satisfactory results.

Management of Vascular Injuries in Penetrating Trauma

Management of vascular trauma remains a challenge and traumatic injuries result in significant morbidity and mortality. Vascular trauma can be broadly classified according to mechanism of injury (iatrogenic, blunt, penetrating, and combination injuries). In addition, this can be further classified by anatomical area (neck, thoracic, abdominal, pelvic, and extremities) or contextual circumstances (civilian and military).

Reconstruction of primary and secondary aortic infections with an antimicrobial graft

INTRODUCTION

In situ reconstruction (ISR) with autologous veins is the preferred method in infectious native aortic aneurysms (INAAs) or vascular (endo)graft infection (VGEI). However, access to biological substitutes can prove difficult and lacks versatility. This study evaluates survival and freedom from reinfection after ISR of INAA/VGEI using the antimicrobial Intergard Synergy graft combining silver and triclosan.

METHODS

From February 2014 to April 2020, 86 antimicrobial grafts were implanted for aortic infection. The diagnosis of INAA/VGEI and reinfection was established based on the Management of Aortic Graft Infection Collaboration criteria. Survival was analyzed using the Kaplan-Meier method and log-rank P values.

RESULTS

The antimicrobial graft was implanted in 32 cases of INAA, 28 of VGI, and 26 of VEI. The median age was 69.0 (interquartile range: 62.0; 74.0), with a history of coronary artery disease (n = 21; 24.4%), chronic kidney disease (n = 11; 12.8%), cancer (n = 21; 24.4%), and immunosuppression (n = 27; 31.4%). Imaging showed infiltration (n = 14; 16.3%), air (n = 10; 11.6%), and rupture (n = 16; 18.6% including 22 aortoenteric fistulae [AEnF]). Symptoms included fever (n = 37; 43.0%), shock (n = 11; 12.8%), and pain (n = 47; 54.7%). Repair was undertaken through a midline laparotomy in 75 cases (87.2%) and coeliac cross-clamping in 19 (22.1%), suprarenal in 26 (30.2%), plus celiac trunk (n = 3), mesenteric (n = 5), renal (n = 13), or hypogastric (n = 4) artery reconstruction, and omental flap coverage (n = 41; 48.8%). For AEnF, the gastrointestinal tract was repaired using direct suture (n = 14; 16.3%) or resection anastomosis (n = 8; 9.3%). Causative organisms were identified in 74 patients (86.0%), with polymicrobial infection in 32 (37.2%) and fungal coinfection in 7 (8.1%). Thirty-day and in-hospital mortality were 14.0% and 22.1% (n = 12 and 19, respectively, 3 INAA [9.4%], 7 VGI [25.0%], and 9 VEI [34.6%]). Seventy patients (81.4%) had a postoperative complication, 44 (51.2%) of whom returned to the operative room. The 1- and 2-year survival rates were 74.0% (95% confidence interval [CI]: 63.3-82.1) and 69.8% (95% CI: 58.5-78.5), respectively. Survival was significantly better for INAA vs VGEI (P = .01) and worse for AEnF (P = .001). Freedom from reinfection was 97.2% (95% CI: 89.2-99.3) and 95.0% (95% CI: 84.8-98.4) with six reinfections (7.0%) requiring two radiological/six surgical drainage and two graft removals. Primary patency was 88.0% (95% CI: 78.1-93.6) and 79.9% (95% CI: 67.3-88.1) with no significant difference between INAA and VGEI (P = .16).

CONCLUSIONS

ISR of INAA or VGEI with the antimicrobial graft showed encouraging early mortality, comparable to the rates found in femoral vein (9%-16%) and arterial allograft (8%-28%) studies, as well as mid-term reinfection. The highest in-hospital mortality was noted for VEI including nearly 50% of AEnF.

Outcomes Following in Situ Reconstruction for Aortic Infection with the Neo-Aortoiliac System and Aortic Homograft

BACKGROUND

In situ reconstruction is one of the primary surgical options for primary aortic and graft and endograft infections. One institution's outcomes following aortic reconstruction with femoro-popliteal vein (i.e., the neo-aortoiliac system) and cryopreserved aortic allografts are described.

METHODS

A retrospective review was performed of any patient who underwent aortic reconstruction with femoropopliteal vein or cryopreserved aortic allograft from 2013-2022 at a single tertiary-care institution.

RESULTS

Twenty four patients underwent in situ reconstruction with the neo-aortoiliac system or with cadaveric allograft for primary or secondary aortic infection from 2013-2022. Short-term (30-day) mortality remains low (3/24 or 12.5%) despite the high incidence of major postoperative complications that necessitated reintervention in 11/24 or 45.8% of the cohort, most often for recurrent intracavitary infection. Gram-negative and drug-resistant pathogens were the most commonly implicated organisms in recurrent intra-abdominal infection. Management of early allograft degeneration is also described with extra-anatomic bypass grafting, conduit/graft embolization, which is then followed by allograft explantation and wide surgical debridement. Despite low short-term (30-day) mortality, all-cause 1-year mortality remains elevated at 38.1% (8/21) in those with an adequate follow-up interval.

CONCLUSIONS

In situ reconstruction for primary or secondary aortic infections results in excellent short-term patient outcomes but is characterized by a high incidence of reintervention and an elevated all-cause 1-year mortality.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Extraanatomic bypass grafting in a patient with an infected femoral defect caused by a rollover accident: a case report

A 59-year-old male patient presented to the emergency department after a tractor rollover accident. His Injury Severity Score was 41 points. He had multiple pelvic bone fractures and a left common femoral artery injury with soft tissue loss. The injured arteries with skin defect were initially managed with endarterectomy and primary repair. However, the sepsis secondary to the infection from a skin defect became uncontrolled. The infected wound developed massive hemorrhage from the repaired arteries. Supportive measures were initiated to achieve hemostasis but unsuccessful. We performed an anastomosis with a prosthetic graft from the common iliac artery to the femoral artery above the knee, avoiding the wound through the lateral side of the anterior superior iliac spine. After revascularization, the patient recovered uneventfully. An extraanatomic graft reconstruction should be considered early when the autologous vein is unsuitable.

Very Late Aortic Endograft Infection With Listeria monocytogenes in an Elderly Man

Endograft infection with Listeria monocytogenes is a rare, potentially devastating complication of endovascular aortic aneurysm repair. To our knowledge, only 8 cases have been reported. We describe the case of a 72-year-old man who presented with L. monocytogenes endograft infection and a 19-cm degenerative aneurysm 9 years after having undergone endovascular repair of an abdominal aortic aneurysm. The infection was successfully treated with open surgical excision of the infected aortoiliac endograft and its replacement with a rifampin-soaked, bifurcated Dacron graft.

Adjuncts to the Management of Graft Aorto-Enteric Erosion and Fistula with in situ Reconstruction

OBJECTIVE

The objective of this retrospective single centre study was to determine whether different enteric reconstruction methods and adjuncts confer a benefit after in situ reconstructions (ISRs) of graft aorto-enteric erosion (AEnE) and fistula (AEnF).

METHODS

Primary endpoints were in hospital mortality and AEnE/F recurrence. Survival was estimated using the Kaplan-Meier method and explanatory factors were searched for using uni- ± multivariable Cox regression analysis. In 2013, a multidisciplinary team meeting was convened and since then the primary operator has always been a senior surgeon.

RESULTS

Sixty-six patients were treated for AEnE (n = 38) and AEnF (n = 28, 42%) from 2004 to 2020. All patients with AEnF presented with gastrointestinal bleeding (vs. 0 for AEnE; p < .001). Signs of infection were seen in 50 patients (76% [37 for AEnE vs. 13 for AEnF]; p < .001). Referrals for endograft infection increased over time (n = 15, 23%; one before 2013 vs. 14 after; p = .002). Most patients underwent complete graft excision (n = 52, 79%) with increasing suprarenal cross clamping (n = 21, 32%; four before 2013 vs. 17 after; p = .015). Complex visceral reconstructions decreased over time (n = 31, 47%; 17 before 2013 vs. 14 after; p = .055), while "open abdomens" (OAs) increased (one before 2013 vs. 22 after; p < .001), reducing operating time (p = .012). In hospital mortality reached 42% (n = 28). Estimated survival reached 47.6% (95% confidence interval [CI] 35.0 - 59.1) at one year and 45.6% (95% CI 33.0 - 57.3) at three years and was higher for AEnE than for AEnF (log rank p = .029). AEnE/F recurrence was noted in 12 patients (18%). Older age predicted in hospital mortality in multivariable analysis (p = .034). AEnE/F recurrence decreased with the presence of a primary senior surgeon (vs. junior; p = .003) and OA (1 [4.4%] vs. 11 [26%] for primary fascial closure; p = .045) in univariable analysis.

CONCLUSION

Mortality and recurrence rates remain high after ISR of AEnE/F. Older age predicted in hospital mortality. Primary closure of enteric defects ≤ 2 cm in diameter reduced operating time without increasing the recurrence of AEnF.

Mycobacterium Bovis Causing Mycotic Aneurysm Secondary to Intravesical Treatment with Bacillus Calmette-Guérin: A Case Report

BACKGROUND

Bacillus Calmette-Guerin (BCG) is a live, attenuated strain of Mycobacterium bovis that is used in the treatment of non-muscle invasive bladder cancer (NMIBC). Vascular complications, including mycotic aneurysms, after BCG therapy are exceedingly rare. In this patient population, the diagnosis of mycotic aneurysms can be delayed or missed due to their non-specific clinical and radiologic presentation. Literature review reveals management of mycotic aneurysms attributable to BCG therapy is widely varied.^2,5-8,12,15 CASE REPORT: We report a patient who presented with mycotic aneurysm formation secondary to BCG treatment for bladder cancer that was repaired with in-line reconstruction utilizing cryoartery and buttressed with omental flap. We suggest this as an alternative treatment to in-line prosthetic graft or extra-anatomic reconstruction.

Fifteen-year, single-center experience with in situ reconstruction for infected native aortic aneurysms

OBJECTIVE

The purpose of the present study was to evaluate the survival and freedom from reinfection for patients with infected native aortic aneurysms (INAAs) treated with in situ revascularization (ISR), using either open surgical repair (OSR) or endovascular aneurysm repair (EVAR), and to identify the predictors of outcome.

METHODS

Patients with INAAs who had undergone ISR from January 2005 to December 2020 were included in the present retrospective single-center study. The diagnosis of INAAs required a combination of two or more of the following criteria: (1) clinical presentation, (2) laboratory results, (3) imaging findings, and (4) intraoperative findings. The primary endpoint was 30-day mortality. The secondary endpoints were in-hospital mortality, estimated survival, patency, and freedom from reinfection using the Kaplan-Meier method. The predictive factors for adverse outcomes were evaluated using the Mann-Whitney U test or the Fisher exact test and multivariate regression analysis.

RESULTS

A total of 65 patients (53 men [81.5%]; median age, 69.0 years; interquartile range, 61.5-75.0 years) were included, 31 (47.7%) were immunocompromised, 60 were symptomatic (92.3%), and 32 (49.2%) had presented with rupture, including 3 aortocaval fistulas (4.6%) and 12 aortoenteric fistulas (18.5%). The most common location was infrarenal (n = 39; 60.0%). Of the 65 patients, 55 (84.6%) had undergone primary OSR with ISR, 3 (4.6%) had required EVAR as a bridge to OSR, and 8 (12.3%) had undergone EVAR as definitive treatment. The approach was a midline laparotomy for 44 patients (67.7%), mostly followed by reconstruction and aortic-aortic bypass (n = 28; 40.6%) and the use of a silver and triclosan Dacron graft (n = 30; 43.5%). Causative organisms were identified in 55 patients (84.6%). The 30-day and in-hospital mortality rates were 6.2% (n = 4) and 10.8% (n = 7). The median follow-up was 33.5 months (interquartile range, 13.6-62.3 months). The estimated 1- and 5-year survival rates were 79.7% (95% confidence interval [CI], 67.6%-87.7%) and 67.4% (95% CI, 51.2%-79.3%). The corresponding freedom from reinfection rates were 92.5% (95% CI, 81.1%-97.1%) and 79.4% (95% CI, 59.1%-90.3%). On multivariate analysis, in-hospital mortality increased with uncontrolled sepsis (P < .0001), rapidly expanding aneurysms (P = .008), and fusiform aneurysms (P = .03). The incidence of reinfection increased with longer operating times (P = .009).

CONCLUSIONS

The selective use of ISR and OSR combined with targeted antimicrobial therapy functioned reasonably well in the treatment of INAAs, although larger, prospective, multicenter studies with appropriately powered comparative cohorts are necessary to confirm our findings and to determine the best vascular substitute and precise role of EVAR as a bridge to OSR or definitive treatment.

In Situ Revascularization with a Rifampicin-Soaked Prosthesis to Treat Bare Iliac Artery Stent Infection: A Case Report

Bare stent infection is an extremely rare complication of endovascular treatment. In such cases, surgical resection of the infected bare stent and revascularization are recommended; however, the revascularization strategy remains controversial. We present a case of a 78-year-old man with an infected aneurysm caused by a bare iliac artery stent infection. We resected the infected aneurysm and performed in situ anatomic reconstruction using a rifampicin-soaked prosthesis with omental coverage. The patient had no reinfection at the 3-year follow-up. Therefore, this procedure may be a useful treatment for bare iliac artery stent infections.

Contemporary Outcomes After Partial Resection of Infected Aortic Grafts

INTRODUCTION

Aortic graft infection remains a considerable clinical challenge, and it is unclear which variables are associated with adverse outcomes among patients undergoing partial resection.

METHODS

A retrospective, multi-institutional study of patients who underwent partial resection of infected aortic grafts from 2002 to 2014 was performed using a standard database. Baseline demographics, comorbidities, operative, and postoperative variables were recorded. The primary outcome was mortality. Descriptive statistics, Kaplan-Meier (KM) survival analysis, and Cox regression analysis were performed.

RESULTS

One hundred fourteen patients at 22 medical centers in 6 countries underwent partial resection of an infected aortic graft. Seventy percent were men with median age 70 years. Ninety-seven percent had a history of open aortic bypass graft: 88 (77%) patients had infected aortobifemoral bypass, 18 (16%) had infected aortobiiliac bypass, and 1 (0.8%) had an infected thoracic graft. Infection was diagnosed at a median 4.3 years post-implant. All patients underwent partial resection followed by either extra-anatomic (47%) or in situ (53%) vascular reconstruction. Median follow-up period was 17 months (IQR 1, 50 months). Thirty-day mortality was 17.5%. The KM-estimated median survival from time of partial resection was 3.6 years. There was no significant survival difference between those undergoing in situ reconstruction or extra-anatomic bypass (P = 0.6). During follow up, 72% of repairs remained patent and 11% of patients underwent major amputation. On univariate Cox regression analysis, Candida infection was associated with increased risk of mortality (HR 2.4; P = 0.01) as well as aortoenteric fistula (HR 1.9, P = 0.03). Resection of a single graft limb only to resection of abdominal (graft main body) infection was associated with decreased risk of mortality (HR 0.57, P = 0.04), as well as those with American Society of Anesthesiologists classification less than 3 (HR 0.35, P = 0.04). Multivariate analysis did not reveal any factors significantly associated with mortality. Persistent early infection was noted in 26% of patients within 30 days postoperatively, and 39% of patients were found to have any post-repair infection during the follow-up period. Two patients (1.8%) were found to have a late reinfection without early persistent postoperative infection. Patients with any post-repair infection were older (67 vs. 60 years, P = 0.01) and less likely to have patent repairs during follow up (59% vs. 32%, P = 0.01). Patients with aortoenteric fistula had a higher rate of any post-repair infection (63% vs. 29%, P < 0.01) CONCLUSION: This large multi-center study suggests that patients who have undergone partial resection of infected aortic grafts may be at high risk of death or post-repair infection, especially older patients with abdominal infection not isolated to a single graft limb, or with Candida infection or aortoenteric fistula. Late reinfection correlated strongly with early persistent postoperative infection, raising concern for occult retained infected graft material.

Improved perioperative mortality after secondary aorto-enteric fistula repair and lessons learned from a 20-year experience

BACKGROUND

Secondary aorto-enteric fistulas (SAEFs) are rare but represent one of the most challenging and devastating problems for vascular surgeons. Several issues surrounding SAEF treatment remain unresolved, including optimal surgical reconstruction and conduit choice. We performed an audit of our experience with SAEFs and highlight aspects of care that have affected outcomes over time with the intent to identify factors associated with best outcomes.

METHODS

We performed a single center, retrospective review of all consecutive SAEF repairs (1999-2019), defined as presence of a false communication between an enteric structure and pre-existing aortic graft. The primary endpoint was 30-day mortality. Secondary endpoints included incidence of complications and overall survival. Time-dependent outcome comparison was performed. Cox proportional hazards modeling and life-table analysis estimated risk and freedom from endpoints.

RESULTS

A total of 57 patients (63% male; n = 36) presented with SAEF (median age, 69 years; interquartile range [IQR], 61-74 years). Median follow-up time was 10 months (interquartile range, 3-21 months. The most common presenting symptoms were gastrointestinal bleeding (60%; n = 34) and abdominal pain (56%; n= 3 2). For the overall cohort, 30% (n = 17) underwent extra-anatomic bypass with aortic ligation, 30% (n = 17) rifampin-soaked Dacron graft, 26% (n = 15) femoral vein (eg, neoaortoiliac system), and 14% (n = 8) cryopreserved aortic allograft. The enteric communication involved the duodenum in 85% (n = 48), and a double-layer hand-sewn primary repair was most commonly employed (61%; n = 35). Thirty-day mortality was 35% (n = 20) with no significant difference between 90 days (39%; n = 22) and 180 days (42%; n = 24). Morbidity was 70% (n = 40), with gastrointestinal (30%; n = 17; leak [9%]), pulmonary (25%; n = 14), and renal (21%) complications being most common. Incidence of reoperation for any vascular and/or gastrointestinal-related complication was 56% (n = 32). One-year and 3-year survival was 54% ± 6% and 48% ± 8%, respectively. Over time, 30- and 90-day mortality improved (odds ratio, 0.1; 95% confidence interval, 0.4-0.5; P = .002) despite no change in patient factors, operative strategy, conduit choice, or morbidity rate. Prehospital history of gastrointestinal bleeding was associated with worse survival (hazard ratio, 2.0; 95% confidence interval, 1.0-3.9; P = .06); however, reconstruction strategy (in-situ vs extra-anatomic bypass), postoperative gastrointestinal and/or vascular complication, omental flap use, and preoperative endovascular aneurysm repair history were not associated with outcome.

CONCLUSIONS

In conclusion, we observed improved short-term mortality despite no significant change in patient presentation or postoperative complications. This highlights increasing institutional experience in selecting the optimal surgical strategy and improved ability to rescue patients experiencing adverse postoperative events. An individualized approach to reconstruction and conduit choice can lead to best outcomes after SAEF management when patients are treated at a high-volume aortic surgery center.

Concomitant paravisceral and thoracic mycotic aortic aneurysms in a cirrhotic patient

In the present case report, we have described concomitant, rapidly expanding, abdominal and thoracic mycotic aortic pseudoaneurysms in a patient who had originally presented for right arm superficial thrombophlebitis and a right-hand abscess in the presence of methicillin sensitive Staphylococcus aureus bacteremia. Within 12 days, the patient had developed a rapidly expanding paravisceral mycotic abdominal aortic pseudoaneurysm that required open surgical repair. After the initial operation, she developed a thoracic mycotic aortic aneurysm that ultimately required open surgical repair. Her postoperative course after the initial operation was complicated by decompensated hepatitis C cirrhosis that required convalescence before repair of the thoracic aneurysm. Follow-up data were available for ≤10 months after the initial operation.

The impact of vascularized tissue flap coverage on aortic graft infection with and without infected graft excision

OBJECTIVES

Aortic graft infection (AGI) is a serious condition associated with a high mortality rate. However, optimal surgical options have not been identified. Therefore, we retrospectively reviewed AGI cases, including those in the thoracic and abdominal regions, with or without fistula formation, to investigate the various options for better outcomes.

METHODS

We reviewed 50 patients who underwent surgical interventions for AGI out of 97 patients with arterial infective disease. The mean patient age was 67 ± 17 years. Fourteen patients (28%) had a fistula with the gastrointestinal tract or lung. A combination of graft excision and vascularized tissue flap coverage was performed in 25 cases (50%). Tissue flap alone, graft excision alone and cleansing alone were performed in 9 (18%), 10 (20%), and 6 cases (12%), respectively.

RESULTS

Total in-hospital mortality rate was 32% (n = 16). In-hospital mortalities in patients with and without fistulas were 43% (6/14) and 28% (10/36), respectively (P = 0.33). Subgroup analysis among patients without fistula demonstrated that the in-hospital mortality rate of the patients with vascularized tissue flap (3/21, 14%) was significantly lower than that of the patients without vascularized tissue flap (7/14, 50%, P = 0.026). Overall 1- and 5-year survival rates were 66% and 46%, respectively. In multivariable analysis, an independent factor associated with in-hospital mortality was vascularized tissue flap (odds ratio 0.20, P = 0.024).

CONCLUSIONS

Vascularized tissue flaps could provide better outcomes for AGI. Graft preservation with vascularized tissue flaps could be a useful option for AGI without fistula.

Infections of the aorta

Infection of the aorta continues to be a clinical challenge with high morbidity and mortality. The incidence varies between 0.6 and 2.6%. There has been a steady increase in graft infections, especially endograft infections, due to increased procedures (0.2 to 5%). Staphylococcus species remains the most common organism; however, gram-negative and rare causative agents are also reported. The clinical presentation can be very diverse and a high degree of suspicion is necessary to diagnose them. Sometimes, they may present as an emergency with rupture or fistulation. Diagnosis is based on a triad of clinical features, microbial cultures and imaging. Culture-specific antibiotics are mandatory during the entire course, but seldom cure alone. Surgical management remains the standard of care and involves an integrated approach involving debridement, reconstruction and use of adjuncts. Various aortic substitutes have been described with advantages and limitations. Pericardial tube grafts have emerged as a good option. Endo-vascular options are practiced mostly as a bridge to definitive surgery. A small role for conservative management is described. Aortic fistulation to the gut and airway carries a very high mortality. There are no large series in the literature to define guideline-directed treatment and most often it is a customized solution. The 30-day mortality remains close to 30%. Outcomes depend on multiple factors including patient's age, the timing of presentation, diagnosis, causative organism, host status and the treatment strategy adopted.

Successful treatment of graft-duodenal fistula after renovisceral debranching thoracic endovascular aortic repair with limited graft resection based on 18F-fluorodeoxyglucose positron emission tomography with computed tomography

We present the case of a patient with a graft-duodenal fistula after renovisceral debranching thoracic endovascular aortic repair. ¹⁸F-fluorodeoxyglucose positron emission tomography with computed tomography showed that the infection was localized to the renovisceral bypass grafts and the right kidney. Based on the preoperative imaging findings, a limited surgery with resection was performed in the fistula, right kidney, and fluorodeoxyglucose-positive bypass grafts, while preserving the fluorodeoxyglucose-negative grafts. No signs of reinfection were reported 2 years after the surgery. Accurate assessment of infection with ¹⁸F-fluorodeoxyglucose positron emission tomography with computed tomography may be useful for performing adequate excision of infected lesions.

Management of aortobronchial fistula: Experience of 14 cases

OBJECTIVES

Aortobronchial fistula (ABF) is rare but lethal condition if left untreated, and the treatment still remains challenging. We retrospectively reviewed data at our Institution and report our experience in the management of ABF.

METHODS

From September 2010 to May 2019, 14 patients (13 men, average age 52 ± 11 years) with ABF were treated in our hospital. Three types of management were applied according to the patients' different clinical presentation, including conservative treatment, that is, antibiotic treatment (n = 3), endovascular repair (n = 7), and open surgery (n = 4). In the open surgery group, Dacron grafts were used, two cases received in situ descending thoracic aortic replacement through left thoracotomy and two cases received extra-anatomic bypass through median thoracoabdominal incision.

RESULTS

In the conservative treatment group (n = 3), two patients died during follow-up, the third was alive in good condition. In the endovascular repair group (n = 7), one patient died 22 days after the endovascular repair because of massive hemoptysis and another patient died 4 days after the procedure because of cerebral infarction. In the medium term, two patients died of massive hemoptysis, and one was lost at follow-up. In the open surgery group (n = 4), one patient died because of massive hemoptysis 2 days after his extra-anatomic bypass procedure, the remaining patients were alive in good condition at follow-up.

CONCLUSIONS

ABF is catastrophic if left untreated. Endovascular repair might be a reasonable temporary bridge solution in emergency cases, but is less durable in the long run. Open surgery, despite more challenging, provides a more definitive treatment for ABF.

Efficacy of antiseptic impregnation of aortic endografts with rifampicin compared to silver against in vitro contamination with four bacteria that frequently cause vascular graft infections

OBJECTIVE

This in vitro study investigates the antimicrobial efficacy of impregnation of commercially available aortic endografts (EG) with rifampicin (RIF) and nanocolloidal silver.

METHODS

Endografts were flushed with 50 mL of RIF 600 mg, 70 mL of a silver-based aqueous solution (AG), or 50 mL of phosphate-buffered saline (PBS) over 15 minutes. Endografts were then retrieved from the sheath and cut in 1 × 1 cm sized graft units (n = 80 of each impregnation), which were then incubated for 1 hour separately with inoculates containing 10⁶ or 10³ bacteria per milliliter (bact/mL) of each of the following bacteria: Staphylococcus epidermidis, Escherichia coli, multisensitive Staphylococcus aureus, and Pseudomonas aeruginosa. After sonication of the graft units, bacterial counts were measured by plating out twice the sonication solution on Mueller-Hinton plates.

RESULTS

RIF showed a statistically significant decrease of colony forming units per milliliter for all four bacterial strains in both concentrations compared with PBS and AG, except for 10³ bact/mL of E coli. AG showed a significant decrease of colony forming units per milliliter compared with PBS only for 10⁶ bact/mL of E coli and was statistically significantly inferior to RIF for all four bacterial strains in both concentrations with the exception of E coli at a concentration of 10³ bact/mL.

CONCLUSIONS

This in vitro study demonstrated infectivity resistance of aortic EG after flushing with RIF. Moreover, the feasibility of flushing aortic EG with a new silver-based agent could be demonstrated, but without statistically significant antimicrobial efficacy compared with native EG.

In situ revascularization with rifampicin-soaked silver polyester graft for aortic infection: Results of a retrospective monocentric series of 18 cases

OBJECTIVE

To evaluate the short and long-term results of in situ prosthetic graft treatment using rifampicin-soaked silver polyester graft in patients with aortic infection.

MATERIAL AND METHOD

All the patients surgically managed in our center for an aortic infection were retrospectively analyzed. The primary endpoint was the intra-hospital mortality, secondary outcomes were limb salvage, persistent or recurrent infection, prosthetic graft patency, and long-term survival.

RESULTS

From January 2004 to December 2015, 18 consecutive patients (12 men and 6 women) were operated on for aortic infection. Six mycotic aneurysms and 12 prosthetic infections, including 8 para-entero-prosthetic fistulas, were treated. In 5 cases, surgery was performed in emergency. During the early postoperative period, we performed one major amputation and two aortic infections were persistent. Intra-hospital mortality was 27.7%. The median follow-up among the 13 surviving patients was 26 months. During follow-up, none of the 13 patients presented reinfection or bypass thrombosis.

CONCLUSION

This series shows that in situ revascularization with rifampicin-soaked silver polyester graft for aortic infection have results in agreement with the literature in terms of intra-hospital mortality with a low reinfection rate.

In situ bypass and extra-anatomic bypass procedures result in similar survival in patients with secondary aortoenteric fistulas

OBJECTIVE

The optimal revascularization modality in secondary aortoenteric fistula (SAEF) remains unclear in the literature. The purpose of this investigation was to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients with SAEF.

METHODS

A retrospective, multi-institutional study of SAEF from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and operative and postoperative variables were recorded. The primary outcome was long-term mortality. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariate analyses were performed.

RESULTS

During the study period, 182 patients at 34 institutions from 11 countries presented with SAEF (median age, 72 years; 79% male). The initial aortic procedures that resulted in SAEF were 138 surgical grafts (76%) and 42 endografts (23%), with 2 unknown; 102 of the SAEFs (56%) underwent complete excision of infected aortic graft material, followed by in situ (in-line) bypass (ISB), including antibiotic-soaked prosthetic graft (53), autogenous femoral vein (neoaortoiliac surgery; 17), cryopreserved allograft (28), and untreated prosthetic grafts (4). There were 80 patients (44%) who underwent extra-anatomic bypass (EAB) with infected graft excision. Overall median Kaplan-Meier estimated survival was 319 days (interquartile range, 20-2410 days). Stratified by EAB vs ISB, there was no significant difference in Kaplan-Meier estimated survival (P = .82). In comparing EAB vs ISB, EAB patients were older (74 vs 70 years; P = .01), had less operative hemorrhage (1200 mL vs 2000 mL; P = .04), were more likely to initiate dialysis within 30 days postoperatively (15% vs 5%; P = .02), and were less likely to experience aorta-related hemorrhage within 30 days postoperatively (3% aortic stump dehiscence vs 11% anastomotic rupture; P = .03). There were otherwise no significant differences in presentation, comorbidities, and intraoperative or postoperative variables. Multivariable Cox regression showed that the duration of antibiotic use (hazard ratio, 0.92; 95% confidence interval, 0.86-0.98; P = .01) and rifampin use at time of discharge (hazard ratio, 0.20; 95% confidence interval, 0.05-0.86; P = .03) independently decreased mortality.

CONCLUSIONS

These data suggest that ISB does not offer a survival advantage compared with EAB and does not decrease the risk of postoperative aorta-related hemorrhage. After repair, <50% of SAEF patients survive 10 months. Each week of antibiotic use decreases mortality by 8%. Further study with risk modeling is imperative for this population.

Cases of two patients with aortoduodenal fistula who underwent emergency operation

•

Aortoduodenal fistula is a rare cause of gastrointestinal bleeding. However, it is life threatening.

•

Diagnosis requires a high level of clinical suspicion, and surgery can offer the best chance of survival.

•

Primary aortoduodenal fistula is often caused by aortic aneurysm without any previous vascular intervention.

•

Secondary aortoduodenal fistula occurs after surgical treatment for abdominal aortic aneurysm.

Introduction

Aortoduodenal fistula (ADF) is a rare but life-threating condition, and it is an important cause of massive gastrointestinal bleeding. Primary ADF often occurs as a result of aortic aneurysm, and secondary ADF develops after the placement of aortic prosthetic graft.

Presentation of cases

Case 1: A 64-year-old man with hematemesis was transferred to our hospital. The patient was diagnosed with primary ADF. Thus, we performed prosthetic graft replacement for an aortic aneurysm, and suturing of the duodenal fistula and duodenojejunal side-to-side anastomosis were performed. He was then discharged on the 35th postoperative day. After 2 years and 10 months, he died of other diseases. Case 2: A 76-year-old man with a history of abdominal aortic aneurysm repair with a prosthetic graft 5 years back who presented with hematemesis and melena was transferred to our hospital. The patient was diagnosed with secondary ADF, and an emergency endovascular aneurysm repair (EVAR) and suturing of the duodenal fistula were perfomed. He was transferred for rehabilitation purposes on the 108th postoperative day but eventually died of pneumonia 6 months after surgery.

Discussion

ADF is associated with high mortality. Initial bleeding is usually minor and often intermittent. However, it leads to severe bleeding and hemorrhagic shock. EVAR is preferred over open surgery because it can be performed faster and is less invasive. Recently, in case of hemorrhagic shock, EVAR is used as first-line treatment.

Conclusion

Accurate diagnosis and immediate treatment are important for the survival of patients with ADF.

Conventional culture diagnostics vs. multiplex PCR for the detection of causative agents of vascular graft infections - results of a single centre observational pilot study

Background: Timely diagnosis of vascular graft infections is of major importance in vascular surgery. The detection of causative microorganisms is needed for specific medical treatment, but conventional culture is often slow, insensitive and inconclusive due to antibiotic pre-treatment. Detection of bacterial DNA by polymerase chain reaction (PCR) might bypass these problems. We hypothesised that multiplex PCR (mPCR) is feasible, fast and sensitive to detect causative microorganisms in vascular graft infections. Patients and methods: We performed a pilot observational prospective study comparing conventional culture and a commercial mPCR. Inclusion criteria were: confirmed graft infection, suspicious imaging, clinical suspicion, anastomotic aneurysm and repeated graft occlusion. Diagnostic methods were performed using identical samples. Time to result, microorganisms and antibiotic resistance in both groups were compared using Student's t-test or nonparametric tests. Results: 22 samples from 13 patients were assessed and 11 samples were negative for bacteria. Some showed multiple germs. In total, we found 15 different organisms. 13 samples matched, 9 had non-concordant results. Out of the mismatches 3 microorganisms identified in PCR were not detected by culture. Time to result with PCR was shorter (median 5 h vs. 72 h, p < 0.001) than with culture. No resistance genes were detected by mPCR, but conventional culture allowed susceptibility testing and revealed resistance in 5 samples. Conclusions: mPCR seems to be a feasible and quick tool to detect causes of vascular graft infections within 24 h and might be helpful in antibiotic pre-treated patients. The detection of antibiotic resistance with mPCR needs improvement for clinical practice.

Cryopreserved Venous Allografts in Supra-inguinal Reconstructions: A Single Centre Experience

OBJECTIVE

This study introduces a novel technique for supra-inguinal arterial reconstructions with cryopreserved femoral vein and caval allografts with a low re-infection rate and an acceptable graft re-intervention rate on early mid term analysis.

METHODS

Patients treated from February 2012 to March 2018 with cryopreserved venous allograft reconstructions owing to infection in the supra-inguinal area were reviewed retrospectively. The primary end points were re-infection and the treatment related mortality rate. Secondary end points were 30 and 90 day and overall mortality and graft re-intervention rate.

RESULTS

Of the 23 patients treated with cryopreserved venous allografts for infection in aorto-iliac area, 21 (91%) patients underwent reconstruction with cryopreserved femoral veins and two (9%) with vena cava. Indications for treatment were aortic graft infections (n = 12 [52%]), mycotic aneurysms (n = 5 [22%]), femorofemoral prosthetic infections (n = 3 [13%]), anastomotic pseudo-aneurysms (n = 2 [9%]), and aortic thrombosis with intestinal spillage (n = 1 [4%]). In hospital and 90 day mortality were 9% (n = 2); overall treatment related mortality during the median follow up of 15 months was 13% (n = 3). During the follow up, two allografts were re-operated on owing to anastomotic dilatation and one because of re-infection, resulting in a re-intervention rate of 13% (n = 3). None of the grafts was lost and there were no amputations. At the end of follow up 17 patients (74%) were alive. Kaplan-Meier estimation for survival was 76% (95% confidence interval [CI] 57%-95%) at one year and 70% (95% CI 49%-91%) at two years.

CONCLUSION

Cryopreserved venous allografts appear to be an infection resistant and reasonably safe reconstruction material in the aorto-iliac axis based upon the early mid term analysis from a single centre experience. Further research is needed to compare their performance with other biological reconstruction material.

Complex two-stage open surgical repair of an aortoesophageal fistula after thoracic endovascular aortic repair

Aortoesophageal fistula after thoracic endovascular aortic repair is a rare but fatal complication, and no clear guidelines exist in the literature for optimal management. Herein, we report a complex case of a patient with an infected thoracic endograft that led to an aortoesophageal fistula. The treatment comprised a two-stage open surgical approach-an extra-anatomic aortic bypass in the first stage, followed by explantation of the infected endograft with ligation of the descending thoracic aorta in the second. This approach controls the focus of infection while allowing flow to the aorta distal to the infected endograft, minimizing visceral ischemia time.

An iliac-appendiceal fistula causing gastrointestinal bleeding

Aortoenteric fistulas are an uncommon cause of gastrointestinal bleeding, and iliac-appendiceal fistulas are an even rarer cause. We describe a case of an iliac-appendiceal fistula in a patient who presented several months after aortic reconstruction with gastrointestinal bleeding. An extensive workup revealed that the source of bleeding was localized to the appendiceal orifice. The patient underwent an appendectomy with a two-stage procedure involving the iliac graft for definitive repair and ultimately recovered well. Despite the rarity of aortoenteric and iliac-appendiceal fistulas causing gastrointestinal bleeding, keeping a high index of suspicion in patients with a prior vascular repair can prevent death.

A meta-analysis of outcomes of in-situ reconstruction after total or partial removal of infected abdominal aortic graft

INTRODUCTION

There is currently a lack of evidence for the relative effectiveness of partial resection (PR) and total resection (TR) before managing abdominal aortic graft infection (AGI). Most authorities agree that TR is mandatory for intracavitary AGI in patients with favorable conditions but there is an increasing number of patients with severe comorbidities for whom this approach is not suitable, resulting in a prohibitive mortality rate. The purpose of this study was to determine the most appropriate indication for TR or PR.

EVIDENCE ACQUISITION

A meta-analysis was conducted on the rates of early/late mortality, amputations and reinfection. A meta-regression was performed with eight variables: patient age, male prevalence, presence of virulent or nonvirulent organisms, urgency, omentoplasty and follow-up.

EVIDENCE SYNTHESIS

Twenty-one studies and 1052 patients were included. For TR and PR, the rates of early mortality and reinfection were 16.8% and 10.5%, 11% and 27%, respectively. For TR urgency and male gender were associated with increased rate of early mortality and male gender, PDF and virulent organisms were associated with increased risk of reinfection. For PR no statistical correlation was analyzable except for PDF with increased risk of reinfection.

CONCLUSIONS

Early mortality rates are higher for TR and reinfection rates are higher for PR. For TR early mortality increases in urgent cases and it is suggested that alternative option must be discussed, reinfection decreases in the presence of nonvirulent organisms and TR seems optimal. For TR and PR reinfection increases in presence of PDF and alternative technique may be more appropriate.

Explantation of infected thoracic endovascular aortic repair

Prosthetic graft infection is a rare and serious complication of thoracic endovascular aortic repair associated with high mortality and posing unique challenges for treatment. The prosthetic graft infection is often identified late as patients present with mild nonspecific symptoms. We describe the successful medical management and surgical explantation of an infected thoracic endograft with an aorta-bronchial fistula, using an inline reconstruction with an antibiotic-soaked synthetic graft. In this report, we provide an example of a patient with an infected thoracic endograft and how inline reconstruction combined with appropriate medical management is an acceptable treatment strategy.

In vitro Evidence of Improved Antimicrobial Efficacy of Silver and Triclosan Containing Vascular Grafts Compared with Rifampicin Soaked Grafts

OBJECTIVES

The aim was to compare the antimicrobial efficacy of four different grafts: a standard graft (Intergard, IG), an IG graft soaked in rifampicin (IGrif), a silver impregnated graft (Intergard Silver, IGS), and a silver + triclosan impregnated graft (Intergard Synergy, IGSy).

METHODS

This was a seven day in vitro study. The IG, IGrif, IGS, and IGSy grafts were each contaminated separately with the following microorganisms: Staphylococcus epidermidis, Methicillin resistant Staphylococcus aureus (MRSA), Escherichia coli, and Candida albicans from both clinical and American Type Culture Collection (ATCC) origins. The in vitro antimicrobial efficacy was evaluated by time to kill assays at T0, T24h, T48h, T72h, and T168h. Bactericidal activity was defined as >3 log₁₀ reduction factor (logRF). Additionally, Rifampicin, triclosan and silver resistance development were screened.

RESULTS

As anticipated for the non-antimicrobial IG, all microorganism strains proliferated. The IGSy and the IGS showed a seven day bactericidal efficacy (>3 logRF) for all tested microorganisms. This efficacy was confirmed at all time points for IGSy only, demonstrating faster bactericidal efficacy than IGS. The IGrif demonstrated a seven day bactericidal efficacy against the ATCC MRSA only, while showing no activity against C. albicans and ATCC E. coli. Regarding ATCC S. epidermidis, clinical MRSA and clinical E. coli, IGrif, although bactericidal at earlier time points, lost its antimicrobial efficacy at seven days leading to the emergence of rifampicin resistant mutants in four of six, two of six, and two of six assays, respectively. Mutant strains were also detected in ATCC MRSA in one of six assays. No triclosan or silver resistance has emerged at T7days.

CONCLUSION

For all microorganisms tested, the Synergy graft combining silver with triclosan demonstrated a more sustainable and efficient seven day antimicrobial activity than the rifampicin soaked graft. The emergence of rifampicin resistant mutants suggests preference for a Synergy graft over a graft soaked in rifampicin, to prevent or treat an infection when a biological solution is not feasible.