The management of aortoduodenal fistula by in situ replacement of the infected abdominal aortic graft

Multi-stage surgery to treat oesophageal fistula that developed after chemoradiotherapy in two patients with oesophageal cancer: A case report

INTRODUCTION AND IMPORTANCE

Oesophageal fistula is a severe complication that may occasionally develop after chemoradiotherapy (CRT) for oesophageal cancer and is difficult to treat.

CASE PRESENTATION

A 51-year-old man who had undergone CRT for oesophageal cancer presented with haematemesis and was diagnosed with a descending aortic aneurysm and an oesophageal fistula. Thoracic endovascular aneurysm repair was performed to achieve haemostasis. After 3 days, the patient underwent subtotal oesophagectomy and cervical oesophagostomy with delivery of a pedicled omental flap to the exposed aortic stent. Six months later, ileocecal reconstruction was performed. The second patient was a 49-year-old woman who had undergone CRT 1 year previously. She complained of leg weakness and gait disorder. After a workup, she was diagnosed with perforation of the posterior wall of the cervical oesophagus with abscess formation and purulent spondylitis. After two spinal fusion surgeries, we performed tracheotomy and drained the cervical region to reduce local infection. After 7 days, she underwent pharyngolaryngoesophagectomy and reconstruction using a gastric conduit, to which a large section of the omental flap was attached. After the multi-stage surgery, oral intake became possible, and both patients were discharged.

CLINICAL DISCUSSION

The optimal treatment strategy for post-CRT oesophageal fistula remains controversial. Radical surgery, including oesophagectomy, is the treatment of choice, although it is associated with high mortality rates. Multi-stage surgery may be useful for reducing surgical stress in moribund patients.

CONCLUSION

We reported two cases involving radiation-induced oesophageal fistula successfully treated by multi-stage surgery without major complications.

Management and Clinical Outcome of Aortic Graft Infections: A Single-Center Retrospective Study

BACKGROUND

This study aimed to evaluate the outcome of various treatment options for aortic graft infection (AGI) patients and identify factors affecting their prognosis.

METHODS

The data of AGI patients from January 2008 to December 2019 were retrospectively collected and analyzed. The primary endpoints were 30-day mortality and perioperative complication-related morbidity; the secondary endpoints were re-infection (RI) rates, primary and secondary graft patency, overall mortality, duration of antibiotic therapy, and the number of antibiotic types used in treatment.

RESULTS

There was no significant difference in the 30-day mortality and perioperative-related complications between the conservative treatment, in-situ reconstruction (ISR), and extra-anatomic reconstruction (EAR) groups. The ISR group had lower re-infection rates and better overall survival rates than the EAR and conservative treatment groups. Different bypass graft conduits had no significant influence on the RI rate or primary and secondary graft patency. AGI patients infected with high-virulence pathogens had higher RI and overall mortality rates than those infected with low virulence pathogens, but this was not statistically significant. Initial procedures prior to the AGI also had no influence on the prognosis of AGI patients. Patients undergoing ISR or EAR surgery received antibiotic therapy for a longer duration than patients undergoing conservative treatment. Patients without RI received more types of antibiotics than patients with RI.

CONCLUSIONS

ISR had lower RI rates and better overall survival rates than EAR and conservative treatment and may be a better choice for patients with AGI. Several factors were found to have no influence on patients' prognosis however, further studies are required.

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.

Treatment of Post-Evar Aortoduodenal Fistula Without Endograft Excision

An 80 year-old gentleman presented with aortoduodenal fistula 2 months after uncomplicated endovascular aneurysm repair (EVAR). Upon laparotomy and fistula takedown, there was no active hemorrhage from the excluded aneurysm. It was theorized the fistula had originated from an occult type II endoleak which had since thrombosed. The duodenum was repaired primarily; the anterior defect in the aneurysm sac was packed and covered with omentum. The patient recovered uneventfully and remains well after 9 months. This is the first case, to our knowledge, of a post-EVAR aortoduodenal fistula successfully treated without endograft excision.

Systematic Review and Meta-Analysis on the Management of Open Abdominal Aortic Graft Infections

OBJECTIVE

Aortic graft infection (AGI) is a disastrous complication with an incidence of 0.2-6% in operated patients. With little or no high quality evidence, the best treatment option remains unclear. Therefore, the literature on the management of open abdominal AGI was systematically reviewed to determine optimal treatment.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review and meta-analysis was conducted for AGI. MEDLINE, Embase, and the Cochrane Database of Systematic Reviews were searched. Methodological quality was assessed using the Methodological Index for Non-randomised Studies (MINORS) score. Primary outcomes were 30 day mortality and one year survival. Secondary outcomes were survival, infection recurrence, limb salvage, and graft patency.

RESULTS

Of 1574 studies identified, 32 papers were included in the study. The overall quality of the studies was moderate, with an average MINORS score of 11.9. Pooled overall 30 day mortality and one year survival were 13.5% (95% CI 10.5-16.4) and 73.6% (95% CI 68.8-78.4), respectively. The lowest 30 day mortality and highest one year survival were found for in situ repair compared with extra-anatomic repair and for prosthetic grafts compared with venous grafts or arterial allografts. The infection recurrence rate was highest for prosthetic grafts.

CONCLUSIONS

There is a lack of well designed, qualitative comparative studies making conclusive recommendations impossible. The current best available data suggests that partial graft removal should be avoided and the lowest 30 day mortality and best one year survival are achieved with in situ repair using prosthetic grafts. Initiatives such as the MAGIC database to collaboratively collect prospective data are an important step forward in obtaining more solid answers on this topic.

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.

Reflection of pioneers: redo thoracoabdominal aortic aneurysm repair controversies in thoracic aortic aneurysm surgery

Reoperative thoracoabdominal aortic aneurysm repair is frequently necessary and brings with it a unique set of challenges. Typically, most reoperative repairs are necessitated by aortic disease progressing into previously healthy aortic tissue from a replaced section of the aorta (an extension of the previous repair) or, to a lesser degree, because of a late complication of prior distal aortic repair (an open or endovascular repair failure). Characterizing the reason for the reoperation as well as the location of prior repair is the first step towards anticipating major outcomes following such repair. Since the introduction of endovascular repair for aortic aneurysms, indications for open repair have become more specific and limited; many centers have justified using endovascular approaches in patients with prior open aortic repair by deeming these patients "high risk" because of their previous incision. Our analysis found that reoperative repairs were not typically subject to worse early outcomes than patients without prior distal aortic repair, except for the more complicated types of reoperation, which involve infection.

Aortic Graft Infections and Aortoenteric Erosions/Fistulae

Aortic graft infections and graft enteric complications are among the most challenging problems faced by vascular surgeons. Prompt, accurate diagnosis and definitive treatment are essential if major morbidity and mortality are to be avoided. In this paper, the clinical presentation, diagnostic evaluation, and contemporary surgical management of aortic graft infections and graft enteric complications are reviewed. Traditional management techniques (extraanatomic bypass with complete graft removal) are described in detail. Newer and more controversial techniques (management of infected aortofemoral graft limb without graft removal and in situ replacement of infected aortic grafts) are discussed and their results compared with those of traditional treatment.

Operative Management of Crossover Femoral-femoral Graft Erosion into Bladder: A Case Report

Erosion of vascular grafts is not uncommon as seen in the recent literature. There have been many case reports documenting the work up and management of erosion of these grafts into bowel. We report a case of a crossover femoral-femoral graft that eroded into the anterior bladder wall and was incidentally found as an adherent bladder stone during cystoscopy. We demonstrate the importance of having a high level of clinical suspicion for eroding vascular grafts when preoperative imaging shows close proximity of graft to bladder.

A Case of Primary Aortoenteric Fistula: Review of Therapeutic Challenges

BACKGROUNDS

Primary aortoenteric fistula (PAEF) is a lethal cause of gastrointestinal bleeding. They mainly originate from eroding abdominal aortic aneurysms into the intestinal wall. Other known causes involve malignancies, infection, corpora aliena, or radiation therapy. Traditional treatment consists of resection of the fistula and extra-anatomic reconstruction. In situ repair and endovascular stenting have offered new therapeutic options in managing this complex entity.

CASE REPORT

A 79-year-old woman presented with a PAEF. She was known with a 3.9-cm abdominal aortic aneurysm and polymyalgia rheumatica. The initial treatment consisted of endovascular stenting. Several months later, she presented with persistent inflammation of the aortic endoprosthesis. The prosthesis and inflammatory tissue were resected, and in situ reconstruction with autologous superficial femoral vein and omentoplasty was performed. Two years later, she remains well with no evidence for infection or bleeding.

CONCLUSIONS

Polymyalgia rheumatica might induce an AEF as in this patient no other provoking factors were retained. The different therapeutic options all have their advantages and disadvantages. In line with this case, we suggest an individualized approach for AEFs. In case of precarious hemodynamical state or life expectancy, endovascular treatment is indicated. Afterward, the possibility and/or necessity of open repair should be discussed. For stable patients with respectable life expectancy in situ repair with autologuous vein or rifampicin-soaked prosthesis (adjusted to comorbidities) might be most appropriate. Extra-anatomic reconstruction still remains a valuable alternative in older patients and in the presence of any other local factors hampering in situ reconstruction.

Prevention and treatment of aortic graft infection

Prosthetic vascular graft infection remains one of the most challenging surgical problems for vascular surgeons. This condition is classically associated with high morbidity and mortality rates. Accurate diagnosis of a vascular graft infection can typically be made based on a thorough history and physical examination; although, infrequently, an extensive radiological evaluation is necessary to establish the clinical finding. Complete graft excision and extra-anatomic bypass grafting remains a commonly accepted surgical treatment strategy. Recent clinical data have supported other treatment modalities, including the use of in situ antibiotic-impregnated graft replacement, in situ allograft replacement and in situ autologous graft replacement. This article will review the pathobiology of aortic graft infection, as well as methods to prevent a prosthetic graft infection. Furthermore, various surgical treatment modalities of aortic graft infection will be discussed.

In situ revascularisation for femoropopliteal graft infection: ten years of experience with silver grafts

Purpose

The purpose of this study was to analyze clinical outcome of patients for femoropopliteal graft infection who were treated by in situ reconstruction with a silver-coated prosthesis.

Basic methods

From December 2001 to December 2011, 27 patients were treated for femoropopliteal graft infection. Twenty patients (74%) were male and seven (26%) were female. Mean age was 65 years. The primary endpoint was recurrence of infection. Secondary endpoints were early and late mortality and morbidity, primary graft patency, major amputation rates and patient survival.

Principal findings

Early reinfection occurred in 11% and late in 8% of patients. Perioperative mortality was 7% and late was 4%. Above-knee amputation was performed in 4% of patients during early postoperative course and in 12% of patients during follow-up. Early and late graft patency was 96% and 72%, respectively.

Conclusions

Results of in situ implantation of silver-coated grafts for femoropopliteal prosthesis infection are according to our opinion acceptable, but the risk of reinfection remains.

Contemporary management of infrarenal aortic graft infection: early and late results in 82 patients

Management of aortic graft infection (AGI) remains contentious. The purpose of this study was to evaluate factors of clinical significance which influence the outcome of different treatment modalities for AGI. From 2000 to 2008, 82 consecutive patients were treated for AGI. In situ reconstruction (ISR) was performed in 63 patients with various conduits, extra-anatomic reconstruction (EAR) in 11, conservative treatment in five and resection without reconstruction in three. The perioperative mortality rate for the series (33%) was similar for EAR and ISR and was higher in patients with secondary aortoenteric fistula ( P < 0.001) in those undergoing emergency aortic reconstruction ( P < 0.001) and in AGI caused by virulent organisms ( P < 0.05). Fifteen (27%) of the surviving patients developed a recurrence of infection (RI). EAR patients were more exposed to RI ( P < 0.04). In conclusion, ISR may be more appropriate for AGI, but this study cannot draw a conclusion relating to the optimal conduit for ISR.

Antibiotic-impregnated grafts for aortic reconstruction

An infected aorta, or aortic graft, is a challenge to manage. Extra-anatomical bypass followed by resection of the infected aorta has been considered standard practice. Outcomes are far from ideal and anatomical constraints make this impossible at the visceral and thoracic aorta. In situ aortic repair is an alternative and can be accomplished in most cases. Use of this technique has been tempered by concerns of graft durability and reinfection. In vitro and in vivo laboratory experiments have demonstrated antibiotics can be bound to polytetrafluoroethylene and Dacron aortic grafts. In animal models, antibiotic-soaked grafts were resistant to infection when seeded with an intravenous bacteria challenge. Purulent, infected aortic grafts created in animal models by direct bacteria inoculation could be successfully replaced in situ with infection-resistant antibiotic-soaked Dacron grafts. The antibiotic of choice is rifampin, which readily binds to commercially available, off-the-shelf gelatin- or collagen-impregnated Dacron. In humans, rifampin-soaked Dacron has not only been used to reconstruct the aorta in the face of infection, but also in elective aortic reconstruction as a prophylaxis against future infection. Outcomes from case series are difficult to interpret because of the heterogeneous nature of patients presenting with aortic infections. Thirty-day mortality ranges from 7% to 21% and morbidity from 2% to 60%. Amputations are rarely seen in these cases, but are common in extra-anatomical bypass from graft occlusion. Reinfection of the rifampin grafts are seen in 4% to 22% of patients, and 5-year survival is near 50%. In the future, the utility of rifampin-soaked Dacron will have to be tested against the emergence of antibiotic-resistant bacteria. Improvements in alternative conduits, such as cryopreserved aortic grafts, may diminish the use of antibiotic-soaked grafts, but it will remain a useful tool in the vascular surgeon's armamentarium.

[Repair of secondary aortoenteric fistulas. A systematic review]

We performed a systematic review of the literature on the diagnosis and treatment of secondary aortoenteric fistulas (AEF). A MEDLINE search was performed of articles published in English or Spanish between January 1991 and August 2006. Diagnostic methods, treatment modalities and the results of surgical treatment were analyzed. The most frequent first aortic surgery associated with AEF was repair of abdominal aortic aneurysm (54.31%). The most common form of presentation was gastrointestinal bleeding. Repair through in situ prosthetic replacement had the lowest early mortality rates (8-13.3%) compared with graft excision and extraanatomic revascularization (18.2-44%). AEF is a serious entity and diagnosis requires a high index of suspicion based on clinical findings and indirect data from imaging techniques (computed tomography). The most appropriate therapeutic option continues to be controversial.

Infección asociada a prótesis vascular: manejo exitoso sin retirada de prótesis

INTRODUCTION

Removal of graft with intravenous antibiotics is traditionally considered the most effective treatment of vascular graft-associated infections. However, an increasing number of reports suggests that this complication can be effectively treated without graft removal.

METHODS

A prospective study to evaluate the outcome of conservative management of vascular graft-associated infection seen in our center was performed. The diagnosis of graft-associated infection was based on microbiological tests, and imaging studies. In our study, patients were hemodynamically stable with functioning vascular graft as per clinical and imaging evaluations. Conservative management included antibiotic treatment and local debridement without removal of vascular graft.

RESULTS

Fourteen patients with vascular graft-associated infection were enrolled in our study. Eleven out of 14 patients (78.6%) responded successfully to conservative management. Treatment failure was reported in 3 patients, 2 of whom required graft removal. After a two-year follow-up, these 14 patients were clinically stable without recurrence of infection.

CONCLUSIONS

Our study has revealed that conservative management of vascular graft-associated infection seems to be effective and should be considered in hemodynamically stable patients with functioning vascular graft.

Endovascular exclusion of mycotic aortic aneurysm

The presence of prohibitive risk may preclude usual surgical management. Such was the case for a critically ill, 60-year-old woman who presented with concomitant, life-threatening conditions. The patient presented with acute central cord syndrome and lower-extremity paraplegia after completing a 6-week course of intravenous antibiotics for methicillin-sensitive Staphylococcus aureus bacteremia and osteomyelitis of the thoracic spine. Radiologic examination revealed bony destruction of thoracic vertebrae T4 through T6, impingement on the spinal cord and canal by an inflammatory mass, and a separate 2.5-cm mycotic aneurysm of the infrarenal aorta. The clinical and radiologic findings warranted immediate decompression and stabilization of the spinal cord, aneurysmectomy, and vascular reconstruction. However, the severely debilitated patient could not tolerate 2 simultaneous open procedures. She underwent emergent endovascular exclusion of the mycotic aneurysm with a stent-graft, followed immediately by laminectomy and stabilization of the thoracic spine. Intraoperative microbiology specimens showed no growth. The patient was maintained on prophylactic antibiotic therapy for 6 months. Fourteen months postoperatively, her neurologic function was near full recovery, and neither surveillance blood cultures nor radiologic examinations showed a recurrence of infection or aneurysm. Although the long-term outcome of endovascular stent-grafts in the treatment of culture-negative mycotic aneurysms is unknown, the use of these grafts in severely debilitated patients can reduce operative risk and enable recovery in the short term.

Complete coverage of in situ aortograft by total omental pedicle flap as the most reliable treatment of aortoesophageal fistula

Aortoesophageal fistula secondary to a thoracic aortic aneurysm is usually a fatal disease with few survivors reported previously. We encountered 2 consecutive patients who were treated successfully with esophagectomy and in situ aorta reconstruction using cryopreserved homograft that was wrapped completely with omental pedicle flap. For the construction of omental flap, the right gastroepiploic artery was resected at the root and all the vessels entering the greater curvature and the transverse colon were resected at the adherent edges. Because the gastroepiploic arcade is totally preserved, large amounts of omental tissue could be obtained, with an excellent blood supply mainly from the left gastroepiploic artery. This type of omental flap is highly mobile, easily transferred to the left hemithorax, and has enough volume to cover the in situ aortic graft completely including anastomosis lines. Thus, our omental coverage appears to be the most reliable method to prevent postoperative graft infection.

Evolution from axillofemoral to in situ prosthetic reconstruction for the treatment of aortic graft infections at a single center

OBJECTIVE

The primary purpose of this study was to analyze the clinical outcome in patients treated for aortic graft infections with in situ reconstruction (ISR). As a secondary aim, the outcomes were compared between patients who had similar clinical characteristics and extent of infection, needed total graft excision, and had either ISR or axillofemoral reconstruction (AXFR).

METHODS

117 consecutive patients treated for aortic graft infection over a 20 year period from January 1981 to December 2001 were identified. 52 patients had prosthetic ISR, 49 had AXFR, and 16 had other reconstructions. The ISR patients treated with total (n = 35) or partial (n = 17) graft excision comprised the primary analysis. A second analysis was done between 34 ISR and 43 AXFR patients (non-concurrent groups), as stated above. Primary outcome measures were early and late procedure-related death, primary graft patency and limb loss. Secondary outcomes were operative morbidity, patient survival, and graft reinfection rates.

RESULTS

There were 40 males and 12 females with a mean age of 69 years treated with ISR. 43 patients had Rifampin-soaked grafts and 39 had omental flap or other autogenous coverage. Operative morbidity occurred in 23 patients (44%). There were 4 early and no late procedure-related deaths after a median follow up of 3.4 years (range, 2 months to 9.6 years). Primary patency and limb salvage rates at 5 years were 89% and 100%, respectively. Graft reinfection occurred in 6 patients (11.5%) and was not associated with procedure-related death. In the comparative analysis, the procedure-related death rate for patients treated with ISR was not different than those treated with AXFR (9% versus 23%; P = 0.11). There was a significant improvement in primary patency between ISR and AXFR at 5 years (89% versus 48%; P = .01). Limb salvage was 100% for ISR and 89% for AXFR at 5 years (P = .06). The incidence of graft reinfection was similar in both groups: 11% for ISR and 17% for AXFR (P = .28). Major complications or procedure-related deaths occurred in 12 patients after ISR (30%) and 26 patients (60%) after AXFR (P < .04).

CONCLUSION

ISR is a safe and effective alternative in the treatment of select patients with aortic graft infection. Graft reinfection occurred in 11.5% of the patients. The graft patency and limb salvages rates are excellent.

Recurrent Aortoenteric Fistula: Case Report and Review

Aortoenteric fistulas (AEFs) are abnormal communications between the aorta and the bowel most frequently resulting from prosthetic graft erosion. Despite advances in surgery and medical technology, these entities are still associated with significant morbidity and mortality for the patient. Multiple case reports and reviews have attempted to elucidate the nature of AEFs in an effort to better characterize and manage these entities. However, reports of recurrence of this process are extremely rare. In this article, we describe a unique case of recurrence of an AEF that was successfully managed with primary aortic oversew and bowel resection. We will also review the literature on AEFs with a comprehensive overview on background, presentation, diagnosis, and current management options.

Neoaortic Reconstruction for Aortic Graft Infection: Need for Endovascular Adjunctive Therapies?

Neoaortic reconstruction using an autogenous conduit is an increasingly accepted option for the management of aortic graft infections. However, this approach is not without technical challenges and potential graft-related problems, some of which can be solved with endovascular techniques. All patients who underwent neoaortic reconstruction with femoral-popliteal vein for aortic graft infection over a 6-year period were identified from the operative registry. Those patients requiring endovascular adjunctive therapies form the basis of this report. Of 17 cases of neoaortic reconstruction for aortic graft infection, five (29%) required endovascular adjunctive procedures. These included stent placement for graft stenosis (n = 3), stent graft placement for proximal anastomotic stenosis (n = 1), and stent graft placement for anastomotic disruption (n = 1). While two of these procedures occurred within 30 days of the original neoaortic reconstruction, three were required during late follow-up. Although there were no direct complications related to the endovascular procedures, the patient with anastomotic disruption died within 30 days of causes unrelated to the endovascular procedure. Primary patency of neoaortic reconstruction was 87% at 30 days and 61% at 3 years, with assisted primary patency increasing to 100% at 3 years after endovascular adjunctive intervention. While neoaortic reconstruction using an autogenous conduit for aortic graft infection has proven durability, it is not without potential early and late graft complications. When graft problems occur, endovascular options are an attractive alternative to reoperative open aortic procedures, especially in the setting of a vastly altered surgical field.

Improved outcomes in the recent management of secondary aortoenteric fistula

OBJECTIVE

We reviewed the presentation, management, and late events in a recent experience with aortic graft-enteric communications (secondary aortoenteric fistula) to identify variables associated with poor outcomes.

METHODS

Since 1991, 29 patients (19 men, 10 women; mean age, 70) presented with a secondary aortoenteric fistula. The duration from aortic graft implantation to aortoenteric fistula development ranged from 8 months to 180 months (mean, 47 months). Presenting symptoms included gastrointestinal bleeding (n = 25), sepsis and retroperitoneal abscess (n = 3), and ruptured para-anastomotic aneurysm (n = 1). One third (10/29) of patients were hypotensive at presentation. Repair was accomplished by graft excision with axillobifemoral bypass (17 simultaneous, 8 staged), graft excision with in situ deep vein replacement (n = 2), or graft excision with rifampin-treated prosthetic replacement (n = 2). Mean follow-up was 51 months, and the incidence of late events was reported by life table methods.

RESULTS

The operative (< or = 30-day) mortality rate was 21%, with shock at presentation (P < .01), the need for preoperative transfusion (P < .01), and use of suprarenal aortic clamping during aortoenteric fistula repair (P = .03) associated with lethal outcome. Cumulative mortality related to aortoenteric fistula management was only 24% within an overall 5-year survival rate of 61%. Freedom from recurrent infection or amputation was 86% and 88% at 5 years, respectively, and assisted graft patency was 79%. Presence of staphylococcal species in 22% of patients and occasional operative findings of adjacent perigraft "biofilm" suggests that underlying indolent graft infection may contribute to the development of aortoenteric fistula in some cases.

CONCLUSION

Outcomes associated with aortoenteric fistula repair were surprisingly favorable in the absence of preoperative hemodynamic instability.

Operative Strategies in Aortic Graft Infections: Is Complete Graft Excision Always Necessary?

The classic approach to aortic graft infections involves complete excision of the graft material with remote reconstruction of the distal circulation. Certain patients may not be well suited for this approach for physiologic or anatomic reasons. This study was undertaken to determine the outcome of partial graft excision in selected patients with aortic graft infection who were not felt to be candidates for complete graft excision. Retrospective analysis of 30 consecutive patients treated with infected grafts arising from the aorta over the past 10 years was performed. Mean interval between graft placement and infection was 5.5 years. Complete graft excision with bypass via clean tissue planes was achieved in 15 patients (group A), and partial or complete graft salvage or in situ graft replacement was performed at the discretion of the surgeon in 15 patients (group B). Perioperative mortality occurred in eight subjects (27%), including six in group A (40%) and two in group B (13%; p = NS). Six patients (20%) developed recurrent infection following graft excision, two (13%) in group A and four (27%) in group B (p = NS). Microorganisms were recovered from 24 of 30 (80%) graft cultures: 13 (43%) were gram positive, 4 (13%) were gram negative, and both gram-positive and gram-negative organisms were recovered from 7 (23%). Identification of culture isolates did not influence either perioperative mortality or the development of recurrent infection. Long-term survival was no different between the groups. We conclude that in certain high-risk patients who may not tolerate complete graft excision, local resection of infected graft segments may be preferable and leads to similar short- and long-term outcome.

Aortic pseudoaneurysm

Reoperative aortic surgery is a therapeutic challenge. We examine a case of reoperative aortic surgery involving a pseudoaneurysm that occurred after surgical treatment of an abdominal aneurysm. A systematic approach to diagnosis, followed by treatment tailored to diagnostic findings, can minimize morbidity.

Early and Long-term Results of Conventional Surgical Treatment of Secondary Aorto-enteric Fistula

OBJECTIVE

To retrospectively evaluate early and late results of surgical treatment of secondary aorto-enteric fistulas (SAEFs) with prosthetic excision and extra-anatomic bypass (conventional treatment) in a single centre institution (teaching hospital).

MATERIALS AND METHODS

Between January 1990 and March 2002, 30 patients underwent conventional surgical treatment for SAEF. Data concerning these operations were collected in a dedicate database and 30-day mortality, patency and limb salvage rates were evaluated by mean of chi-square test and logistic regression analysis. Clinical and ultrasonographic follow-up was performed; late results were evaluated by mean of Kaplan-Meyer curves.

RESULTS

Thirty day mortality rate was 26% (8 patients). Timing and sequence of interventions (simultaneous or staged, prosthetic excision or revascularization before) had no significative influence on perioperative mortality. There were six extranatomic bypass thromboses at 30 days, but no amputation. Mean duration of follow-up was 24 months; estimated 12- and 24-month survival rates were 60 and 50%, respectively. There were better results in terms of long-term survival in patients undergone prosthetic graft excision before. Primary patency rate was 62% and limb salvage rate was 95%, both at 24 months. Two prosthetic graft reinfections occurred during follow-up (9%). Cumulative reinterventions rate during follow-up was 18%.

CONCLUSIONS

Conventional surgical treatment of SAEF permitted, in our experience, satisfactory early and long terms results, with fair rates of patency and limb salvage. Surgical timing and sequence do not seem to affect early results.

Graft-preserving treatment for vascular graft infected with Staphylococcus aureus with antibiotic-releasing porous apatite ceramic in the rabbit

OBJECTIVE

This study was undertaken to investigate whether infection of a vascular graft with Staphylococcus aureus can be treated in situ by applying antibiotic-loaded porous apatite ceramic, in a rabbit model.

METHODS

Teicoplanin (TEIC) was loaded onto a beta-tricalcium phosphate (TCP) block, a type of porous apatite ceramic. The activity of TEIC released from the antibiotic-loaded TCP block was examined in vivo. A vascular graft was patched onto the abdominal aorta in 24 rabbits, and S aureus was applied directly on it. Seven days postoperatively, each rabbit underwent repeat laparotomy, and retroperitoneal abscess around the prosthetic vascular patch was debrided. Animals were divided into four groups of 6 rabbits each. In group 1 only debridement was carried out. In groups 2 and 3, solution containing 40 or 60 mg of TEIC, respectively, was applied to the prosthetic vascular patch. In group 4, an antibiotic-loaded TCP block (63 +/- 6.6 mg of TEIC) was placed around the graft. Three weeks after the second operation, the graft, the tissue around it, and arterial blood were collected and cultured.

RESULTS

TEIC activity was maintained for 28 days in vivo. In group 1, bacterial cultures of the prosthetic vascular graft and the tissue around it were positive in 5 animals and negative in 1 animal (infection rate, 83%). In both groups 2 and 3, cultures were positive in 3 animals and negative in 3 animals (infection rate, 50%). In group 4, cultures were negative in all animals (infection rate, 0%). Blood cultures were negative in all animals. Infection rate in group 4 was significantly lower than that in group 1 (P =.03), and was also lower than that in groups 2 and 3, but the difference was not significant.

CONCLUSIONS

Use of slow-release antibiotic loaded onto a TCP block, along with debridement, may control infection in vascular grafts in situ, averting the necessity to remove the graft.

Endovascular repair of para-anastomotic aneurysms of the aorta and iliac arteries: preferred treatment for a complex problem

PURPOSE

Standard surgical repair of para-anastamotic aneurysms (PAAs) of the abdominal and thoracic aorta and the iliac arteries has been associated with high morbidity and mortality rates. We reviewed our continuing experience with endovascular repair of these lesions to determine whether this approach is favorable and durable.

METHODS

All patients with PAAs of the aorta or iliac arteries who underwent endovascular treatment of their lesions between August 1993 and July 1999 were prospectively followed up, and data on age, previous aortic pathology and surgery, size of PAA, time to diagnosis, and symptoms at presentation were recorded. Preoperative, intraoperative, and postoperative imaging studies were analyzed. All patients had endovascular stent-grafts placed under digital fluoroscopic guidance in the operating room. Data on intraoperative and postoperative complications, mortality, and endoleaks were reviewed.

RESULTS

From August 1993 to July 1999, 28 patients (20 men, 8 women) had 35 PAAs of the aorta or iliac arteries. There were 5 thoracic aortic, 12 abdominal aortic, and 18 iliac artery PAAs. Three patients had a contained rupture of their PAA. All patients who had originally undergone reconstruction for occlusive disease had lesions consistent with false aneurysms, whereas 73% of the aortic or iliac PAAs in patients originally treated for aneurysm disease appeared to be true aneurysms. Thirty-four of 35 PAAs were successfully excluded with stent-grafts (97%). There was one death at 30 days (3.6%) in a patient who was successfully treated endovascularly for a contained rupture of a thoracic PAA. There were four major postoperative complications (14.2%) in the 28 patients who were treated. One patient had continued perfusion of a thoracic aortic PAA (type I endoleak). The in-hospital length of stay after endovascular repair of PAA was 4 days (range, 1-18 days). The mean follow-up period was 21 months (range, 1-68 months).

CONCLUSION

Endovascular repair of aortic and iliac artery PAAs is technically feasible and provides a high rate of lesion exclusion. Morbidity and mortality rates appear lower than those reported for open surgical repair. These patients can typically be discharged by the second postoperative day. Endovascular therapy for stable ruptured PAAs can be successfully performed and should be considered as an option only when appropriate devices and expertise are available. For uncomplicated PAAs of the aorta and iliac arteries, endovascular therapy may be more favorable than surgical repair.

Primary aortoenteric fistula related to septic aortitis

CONTEXT

Primary aortoenteric fistulas usually result from erosion of the bowel wall due to an associated abdominal aortic aneurysm. A few patients have been described with other etiologies such as pseudoaneurysm originating from septic aortitis caused by Salmonella.

OBJECTIVE

To present a rare clinical case of pseudoaneurysm caused by septic aortitis that evolved into an aortoenteric fistula.

CASE REPORT

A 65-year-old woman was admitted with Salmonella bacteremia that evolved to septic aortitis. An aortic pseudoaneurysm secondary to the aortitis had eroded the transition between duodenum and jejunum, and an aortoenteric fistula was formed. In the operating room, the affected aorta and intestinal area were excised and an intestine-to-intestine anastomosis was performed. The aorta was sutured and an axillofemoral bypass was carried out. In the intensive care unit, the patient had a cardiac arrest that evolved to death.

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

BACKGROUND

In situ treatment of artery/graft infection has distinct advantages compared to vessel excision and extra-anatomic bypass procedures. Based on animal studies of a rifampin-soaked, gelatin-impregnated polyester graft that demonstrated prolonged in vivo antibacterial activity, this antibiotic-bonded graft was used selectively in patients for in situ treatment of low-grade Gram-positive prosthetic graft infections or primary aortic infections not amenable to excision and ex situ bypass.

METHODS

In a 5-year period (1995-1999), 27 patients with prosthetic graft infection (aortofemoral, n = 18, femorofemoral, n = 3; axillofemoral, n = 1) or primary aortic infection (mycotic aneurysm, n = 3; infected AAA, n = 2) underwent excision of the infected vessel and in situ replacement with a rifampin soaked (45-60 mg/ml for 15 min) gelatin-impregnated polyester graft. All prosthetic graft infections were low grade in nature, caused Gram-positive bacteria (Staphylococcus epidermidis, 16; Staphylococcus aureus, 5; Streptococcus, 1), and were treated electively. Patients with mycotic aortic aneurysm presented with sepsis and underwent urgent or emergent surgery.

RESULTS

Two (8%) patients died-1 as a result of a ruptured Salmonella mycotic aortic aneurysm and the other from methicillin-resistant S. aureus infection following deep vein replacement of an in situ replaced femorofemoral graft. No amputations or late deaths as the result of vascular infection occurred in the 25 surviving patients. Two patients developed recurrent infection caused by a rifampin-resistant S. epidermidis in a replaced aortofemoral graft limb and were successfully treated with graft excision and in situ autogenous vein replacement. Eighteen patients remain alive and clinically free of infection after a mean follow-up interval of 17 months.

CONCLUSIONS

In situ replacement treatment using a rifampin-bonded prosthetic graft for low-grade staphylococcal arterial infection was safe, durable, and associated with eradication of clinical signs of infection. Failure of this therapy was the result of virulent and antibiotic-resistant bacterial strains.

Management of Patients with Prosthetic Vascular Graft Infection

Management of patients with infected prosthetic vascular grafts is one of the most difficult challenges faced by the vascular surgeon. Patients often present with nonspecific symptoms, but delay in treatment can lead to life-threatening sepsis and/or hemorrhage. Fortunately, prosthetic vascular graft infection is uncommon, with the incidence varying between 1 and 6 per cent, depending on the location of the graft. Initially, the potentially infected vascular graft should be imaged using either CT or magnetic resonance imaging, with radionuclide studies being reserved for those instances in which imaging studies do not confirm or exclude the diagnosis of infection. Current treatments for prosthetic vascular graft infection include attempted graft preservation, graft removal with in situ graft replacement (using autogenous or new prosthetic grafts), and graft removal with extra-anatomic bypass. Morbidity and mortality associated with treatment, likelihood of long-term limb salvage, and likelihood of persistent or recurrent infection vary among these types of treatment. Therefore, in an individual patient with a prosthetic vascular graft infection, many things must be considered to appropriately determine the treatment most likely to achieve eradication of the infection and long-term limb salvage with the lowest risk. Regardless, with appropriate application of the techniques currently available for treatment of prosthetic vascular graft infection, long-term elimination of infection and limb preservation can be achieved in the great majority of patients with this grave problem.

The results of in situ prosthetic replacement for infected aortic grafts

BACKGROUND

Treatment of aortic graft infection with graft excision and axillofemoral bypass may carry an increased risk of limb loss, aortic stump blowout, and pelvic ischemia. A review of patients with aortic graft infection treated with in situ prosthetic graft replacement was undertaken to determine if mortality, limb loss, and reinfection rates were improved with this technique.

METHODS

The clinical data of 25 patients, 19 males and 6 females, with a mean age of 68 years (range 35 to 83), with aortic graft infection, treated between January 1, 1989, and December 31, 1998, by in situ prosthetic graft replacement were reviewed. Follow-up was complete in the 23 surviving patients and averaged 36 months (range 4 to 103).

RESULTS

Twenty aortofemoral, 3 aortoiliac, and 2 straight aortic graft infections were treated with excision and in situ replacement with standard polyester grafts in 16 patients (64%), or with rifampin-soaked collagen or gelatin-impregnated polyester grafts in 9 patients (36%). Fifteen patients (60%) had aortic graft enteric fistulas, 8 patients (32%) had abscesses or draining sinuses, and 2 patients (8%) had bacterial biofilm infections. Thirty-day mortality was 8% (2 of 25). There were no early graft occlusions or amputations. There was one late graft occlusion. There were no late amputations. The reinfection rate was 22% (5 grafts). All reinfections occurred in patients operated upon for occlusive disease. Only one reinfection occurred in the rifampin-soaked graft group (11% versus 29%, P = NS). Reinfection tended to be lower in patients with aortoenteric fistulas and without abscess. Autogenous tissue coverage provided statistically significant protection against reinfection. There were no late deaths related to in situ graft infection.

CONCLUSIONS

Patients treated with in situ graft replacement had an 8% mortality and 100% limb salvage rate. Reinfection rates were similar to those of extra-anatomic bypass, but a trend of lower reinfection rates with rifampin-impregnated grafts was apparent. Patients with aortoenteric fistula and without abscess appear to be well treated by the technique of in situ prosthetic grafting and autogenous tissue coverage.

Improved results with conventional management of infrarenal aortic infection

PURPOSE

Interest in alternative methods, such as autogenous vein grafts and aortic allografts, for the management of infrarenal aortic infection (IRAI) has been stimulated by the historically disappointing results with conventional surgical management. Recently, there have been dramatic improvements in the results of axillofemoral bypass grafting (AXFB) followed by excision of the IRAI that have gone relatively unrecognized. The purpose of this report is the presentation of modern-day results in the treatment of IRAI with conventional surgical methods.

METHODS

From January 1, 1983, through June 30, 1998, patients with IRAI underwent treatment with AXFB and complete excision of the IRAI. The patients were followed for survival, limb salvage, and AXFB graft patency. The results were tabulated with life-table methods.

RESULTS

During the 15-year study period, 60 patients (51 men, nine women; mean age, 68 years) underwent treatment for IRAI (50 graft infections, including 16 graft-enteric fistulae, and 10 primary aortic infections). The mean follow-up period was 41 months. The perioperative mortality rate was 13% (12% for graft infection, and 20% for primary infection). The overall 2-year and 5-year survival rates were 67% and 47%, respectively. The limb salvage rates at 2 and 5 years were 93% and 82%, respectively. The 5-year primary AXFB graft patency rate was 73%.

CONCLUSION

These results show an improvement with the conventional management of IRAI equal or superior to those results reported with alternative methods, including femoral vein grafts or aortic allografts. These results should be regarded as the modern standard with which alternative therapies can be compared.

In situ replacement of infected aortic grafts with rifampicin-bonded prostheses: the Leicester experience (1992 to 1998)

PURPOSE

Prosthetic graft infection after aortic aneurysm surgery is a life-threatening complication. Treatment options include total graft excision and extra-anatomic bypass grafting or in situ replacement of the graft. The latter option is gaining increasing popularity, but the long-term outcome remains uncertain, particularly in light of the increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA). We performed a prospective nonrandomized study to assess the outcome after graft excision and in situ replacement with a rifampicin-bonded prosthesis for the treatment of major aortic graft infection.

METHODS

In a 6-year period from January 1992 to December 1997, 11 patients (eight men, three women) with major aortic graft infection underwent total graft excision and in situ replacement with a rifampicin-bonded prosthesis. The median age of the patients was 66 years (range, 49 to 78 years). Four patients had a hemorrhage from an aortoenteric fistula, three had a retroperitoneal abscess, two had graft occlusion, one had a perigraft collection shown by means of computed tomography, and one had a ruptured suprarenal false aneurysm. Organisms were cultured from 10 patients.

RESULTS

MRSA was isolated in two patients, both of whom had originally undergone repair of a ruptured abdominal aortic aneurysm. Two patients died (18.2%) within 30 days, and three patients (27.6%) had nonfatal complications (peritoneal candidiasis, transient renal impairment, and profound anorexia). Two patients died late in the follow-up period. Seven patients remain alive and clinically free of infection.

CONCLUSION

The long-term results after total graft excision and in situ replacement with a rifampicin-bonded prosthesis appear to be favorable. However, MRSA aortic graft infection appears to be associated with a poor prognosis.

Aortoduodenal fistula: a late complication of intraluminal exclusion of an infrarenal aortic aneurysm

During recent years, considerable clinical experience has been gained with endoluminal stent-graft procedures. Several studies have shown promising results up to a period of 4.5 years. However, long-term follow-up studies are still limited. Late endoleaks caused by stent-graft migration, disconnection of single components in modular stent-grafts, and limb thrombosis have been observed as long-term complications. We report a case in which a migrated and kinked bifurcated stent-graft caused an aortoduodenal fistula 20 months after stent-graft insertion. To our knowledge, such a complication has not been reported before.

Aortic graft infection: the value of percutaneous drainage

OBJECTIVE

The goal of this study was to compare patients with aortic graft infection treated by primary percutaneous drainage with patients who initially underwent surgery.

MATERIALS AND METHODS

A retrospective review of 23 consecutive patients treated for aortic graft infection was performed. Eleven patients were initially treated with percutaneous drainage and 12 were treated with surgery. The morbidity, mortality, and postprocedural reintervention rates and clinical outcome were analyzed for each group.

RESULTS

The septic process resolved in nine (82%) of 11 patients treated with percutaneous drainage. Of these nine patients, four were treated with percutaneous drainage alone. Drainage was followed by removal of the infected prosthetic graft in the remaining five patients. In the surgical group, sepsis resolved in only four patients (33%) (p = .036). No periprocedural deaths occurred in the percutaneous drainage group, whereas six patients in the surgical group died in the perioperative period (p = .014).

CONCLUSION

Percutaneous drainage can be used as an initial form of treatment in the management of aortic graft infections. Surgery after percutaneous drainage appears to be safer than surgery alone.

Treatment of vascular graft infection by in situ replacement with cryopreserved aortic allografts: an experimental study

PURPOSE

The purposes of this study were to prove the efficacy of cryopreserved aortic allografts to treat an established vascular graft infection by in situ replacement in an animal model and to evaluate the role of the antibiotics normally used to decontaminate the allografts.

METHODS

Twenty-three dogs underwent infrarenal aortic replacement with a gelatin-sealed knitted polyester graft contaminated in vitro by Staphylococcus epidermidis RP-62. One week later, the 18 surviving animals underwent reoperation for graft removal and were randomized into three groups for in situ replacement: group I (control, n = 6) received a new gelatin-sealed graft; group II (n = 6) received a non-antibiotic-treated cryopreserved allograft; and group III (n = 6) received an antibiotic-treated cryopreserved allograft. Control grafts and allografts were removed 4 weeks after the initial intervention for quantitative bacteriologic analysis and histologic analysis. Bacteriologic results were expressed as colony-forming units per square centimeter of graft material. Qualitative bacteriologic analysis was also obtained from perigraft fluid and tissue.

RESULTS

All of the initially implanted grafts and all of the control grafts (group I) were infected at the time of removal. In group II, three out of six allografts were not totally incorporated, whereas in group III incorporation was always complete, with a significantly decreased inflammatory reaction. All of the antibiotic-treated allografts were sterile, whereas three untreated allografts grew bacteria.

CONCLUSIONS

In this model, cryopreserved aortic allografts were more resistant to reinfection than synthetic grafts after in situ replacement of an infected prosthetic graft. However, the antibiotic loading of the cryopreserved aortic allograft appears to be essential to obtain optimal therapeutic effects.