Treatment of Aorto-iliac and Infrainguinal Vascular Infections with a Prefabricated Bovine Pericardial Graft

BACKGROUND

The use of biological grafts provides acceptable mid- and long-term results in native or prosthetic vascular infections. Several reports describe the successful use of bovine pericardium in case of vascular infections, mainly as a large patch to be sutured as a tubular graft. Recently, a novel prefabricated bovine pericardium graft (Biointegral Surgical No-React® Inc, Mississauga, ON, Canada) has been introduced in clinical practice with promising results. In this study, we report our preliminary experience utilizing Biointegral Surgical graft in case of native and or prosthetic aorto-iliac and infrainguinal infection.

METHODS

We retrospectively analyzed data from 20 patients with native or prosthetic aorto-iliac and infrainguinal infection who underwent in situ reconstruction (ISR) with a Biointegral Surgical No-React bovine pericardium prosthesis between October 2020 and February 2023 at the Vascular Surgery Unit of the Fondazione Policlinico Universitario Gemelli - IRCCS in Rome, Italy. All patients followed a standardized protocol including postoperative anticoagulation and long-term intravenous antibiotics.

RESULTS

The indication for surgery was: mycotic aortic aneurysm in 4 patients (20%), graft infection after abdominal aortic repair in 11 patients (55%), peripheral graft infection in 5 patients (25%). Complete excision of the infected aorta or prosthetic graft, surgical debridement and ISR were performed in all patients. Hospital mortality rate was 5% (n = 1) and graft-related mortality of 0%. During follow-up (median 13 months, range 6-34 months), reinfection was 5.2% and primary graft patency 94.7%.

CONCLUSIONS

The use of prefabricated bovine pericardial grafts represents a promising option for the treatment of native and prosthetic aorto-iliac and infrainguinal infections. The application of this biological graft with a standardized postoperative protocol has been associated with a satisfactory patency and reinfection rate without increased bleeding complications.

Chimney endovascular aneurysm repair-induced mesenteric ischemia: a report of an extremely rare complication

The chimney endovascular aneurysm repair (Ch-EVAR) technique has progressively increased in popularity in the treatment of complex aortic aneurysms. However, the long-term results of this technique still must be assessed, especially in comparison to custom-made solutions. The patency of chimney grafts has always been one of the important issues with the Ch-EVAR technique. However, interactions between nonstented aortic side branches and chimney stent grafts have rarely been discussed. In the present case report, we describe a rare case of mesenteric ischemia due to superior mesenteric artery ostium coverage by the misalignment of a renal stent graft in a Ch-EVAR.

Severe local wound infections after vascular exposure in the groin and other body areas: Prevention, treatment and prognosis

Severe surgical site infections (SSIs) are a frequent nosocomial complication after vascular interventions, an important cause of postoperative morbidity, and a substantial burden to the health care system. Patients undergoing arterial interventions are at elevated risk of SSIs, possibly because of the presence of several risk factors in this patient population. In this review, we examined the available clinical evidence for the prevention, treatment, and prognostication of postoperative severe SSIs after vascular exposure in the groin and other body areas. Results from studies evaluating preoperative, intraoperative, and postoperative preventive strategies and several treatment options are reviewed. In addition, risk factors for surgical wound infections are analyzed in detail and related evidence from the literature is highlighted. Although several measures have been implemented over the time to prevent them, SSIs continue to pose a substantial health care and socioeconomic challenge. Therefore, strategies to decrease the risk and improve the treatment of SSIs for the high-risk vascular patient population should be the focus of continuing improvement and critical review. This review aimed at identifying and reviewing the current evidence for preventing, treating, and performing stratification according to the prognosis of postoperative severe SSIs after vascular exposure in the groin and other body areas.

"Redo" 2D-3D Fusion Technique during Endovascular Redo Aortic Repair

PURPOSE

The present study aims to describe a new 2D-3D fusion registration method in the case of endovascular redo aortic repair and compare the accuracy of the registration using the previously implanted devices vs. bones as landmarks.

MATERIALS AND METHODS

This single-center study prospectively analyzed all the patients that underwent elective endovascular re-interventions using the Redo Fusion technique between January 2016 and December 2021 at the Vascular Surgery Unit of the Fondazione Policlinico Universitario A. Gemelli (FPUG)-IRCCS in Rome, Italy. The fusion overlay was performed twice, first using bone landmarks (bone fusion) and the second using radiopaque markers of a previous endovascular device (redo fusion). The pre-operative 3D model was fused with live fluoroscopy to create a roadmap. Longitudinal distances between the inferior margin of the target vessel in live fluoroscopy and the inferior margin of the target vessel in bone fusion and redo fusion were measured.

RESULTS

This single-center study prospectively analyzed 20 patients. There were 15 men and five women, with a median age of 69.7 (IQR 42) years. The median distance between the inferior margin of the target vessel ostium in digital subtraction angiography and the inferior margin of the target vessel ostium in bone fusion and redo fusion was 5.35 mm and 1.35 mm, respectively (p ≤ 0.0001).

CONCLUSIONS

The redo fusion technique is accurate and allows the optimization of X-ray working views, supporting the endovascular navigation and vessel catheterization in case of endovascular redo aortic repair.

Type 1A Endoleak after TEVAR in the Aortic Arch: A Review of the Literature

Aortic arch repair is a challenging intervention. Open surgical repair is still considered the gold standard, but in high-risk patients, it is not always a reasonable option, making endovascular approaches an enticing, when not the only available, alternative for treatment. The strategies more commonly adopted are surgical supra-aortic trunk (SAT) rerouting followed by deployment of a standard thoracic endoprosthesis, chimney techniques, custom-made scalloped, fenestrated, and branched devices, and in situ or physician-modified fenestrations. If we excluded techniques involving SAT rerouting where the arch anatomy is surgically modified in order to make deployment in the aortic arch of a standard thoracic endoprosthesis possible, in the other techniques, one or more SATs are incorporated in the thoracic endoprosthesis. In these cases, no matter what solution is adopted, because of the morphology of the aorta at this level, achieving an ideal sealing is extremely difficult, and endovascular treatments of the arch are burdened by an increased risk of type IA endoleaks. PubMed, EMBASE, and Cochrane Library were searched. We identified 1277 records. After reading titles, abstracts, and full texts, we excluded 1231 records. Exclusion criteria were low-quality evidence, abstracts, case reports, conference presentations, reviews, editorials, and expert opinions. A total of 48 studies were included, for a total of 3114 patients. A type IA endoleak occurred in 248 patients (7.7%) with a mean incidence of 18.8% in chimney procedures, 4.8% and 3%, respectively, in fenestrated and branched devices, and 2.2% in in situ fenestration. We excluded from our analysis scalloped technology that is used when the target vessel originates from a healthy landing zone and represents a different anatomical setting. Type IA endoleaks are a concern with all types of endovascular aortic arch repair, and they can compromise the outcomes of the procedure. The rate of type IA endoleaks appears to be significantly higher in chimney procedures. In order to maximize sealing, whenever possible, endovascular repair of the arch should be achieved with custom-made fenestrated devices. However, chimney configurations are still a valuable solution particularly in the emergency setting, although in such a procedure, to guarantee accurate postoperative management and follow-up, an imaging protocol could be useful.

Management of mycotic aorto-iliac aneurysms: a 30-year monocentric experience

OBJECTIVE

This study aims to analyze the early and late outcomes of our 30-year experience with mycotic aneurysms of the abdominal aorta and iliac arteries.

PATIENTS AND METHODS

This retrospective cohort study compared the outcomes of all the patients with mycotic aneurysm, by analyzing prospectively collected data between September 1989 and October 2019 from the Unit of Vascular Surgery of Fondazione Policlinico Universitario Gemelli - IRCCS in Rome, Italy.

RESULTS

Twenty-three patients with mycotic aneurysm were included. Twenty-two patients underwent surgery; one patient arrived at the emergency room with unstable clinical conditions and died before being treated. Fourteen cases (60.9%) were located at the infrarenal aorta, while three cases (13.0%) were pararenal aortic aneurysms. Six cases (26.1%) had an iliac arteries localization. Seventeen patients (77.3%) underwent open surgical repair aneurysmectomy with in situ reconstruction, while three cases (13.6%) underwent extra-anatomic revascularization. Three patients (13.6%) underwent the placement of an endoprosthesis, of whom two underwent hybrid procedures, and one EVAR. The latter underwent an early conversion to open repair due to a type I endoleak. The mean length of hospital stay was 35 ± 18.7 days. Five patients (22.7%) died in the immediate postoperative period. In the follow-up of 45.5 ± 41.3 months (range 2-156), we documented six deaths (35.3%), of whom two (11.8%) were aortic-related for a 34.8% overall aortic-related mortality. Eleven patients were alive, with an overall survival of 47.8%.

CONCLUSIONS

Mycotic aneurysm is an extremely rare and varied pathology. Open surgical repair showed to be a safe approach because of a complete and aggressive debridement of local infected tissues, with an acceptable long-term mortality rate.

Treatment of juvenile cystic adenomyoma by sclerotherapy with alcohol instillation: A case report

Adenomyosis is characterized by the presence of ectopic endometrial tissue within the myometrium. Treatment options ranges from use of non-steroidal anti-inflammatory drugs and hormonal suppression for symptomatic relief, to endometrial ablation or even hysterectomy. In this paper we report the case of successful ultrasound-guided aspiration of focal adenomyosis with intracavitary alcohol instillation in a young patient with symptomatic juvenile cystic adenomyoma. This is the second report of the treatment of sclerotherapy by alcohol instillation, which may be considered as an alternative modality in treating the cases of symptomatic adenomyoma.

TEVAR for traumatic thoracic injury with the first-generation stent graft

Thoracic endovascular aortic repair (TEVAR) is a life-saving treatment for blunt thoracic aortic injury. We report long-term outcomes of two young patients who underwent TEVAR for blunt thoracic aortic injury with first-generation thoracic stent grafts. The off-label use of the endograft affected the outcomes: one case of open surgery conversion due to an aortoesophageal fistula and one case of endovascular relining for a voluminous pseudoaneurysm associated with a type III endoleak. Long-term follow-up is crucial in TEVAR, especially in case of a first-generation device used in an urgent setting.

A Rare Case of Dysplastic Axillary Artery Aneurysm Associated with Arteriovenous Malformation

BACKGROUND

Axillary artery aneurysms are rare conditions, and their causes are various. They can determine severe complications, so the treatment is extremely important.

METHODS

We report the case of a young man affected by a saccular axillary artery aneurysm associated with intramuscular arteriovenous malformation, without symptoms except for the presence of a pulsatile mass. Duplex scan and computed tomography scan have been essential for a correct diagnosis and planning of the treatment. At first, the patient was submitted to coil embolization of an efferent vessel, and then he was treated surgically through ligation and detachment of the aneurysm and replacement of part of the axillary artery with a Dacron graft (Vascutek, Inchinnan, Renfrewshire, Scotland, UK).

RESULTS

Follow-up at 1 and 6 months revealed normal patency of the axillary arterty and the prosthetic graft with complete exclusion and thrombosis of the aneurysm sac.No sensitive nor motor deficit were observed.

CONCLUSIONS

Aneurysms of the axillary artery associated with intramuscular arteriovenous malformations are very rare, but have to be suspected. The treatment is challenging and can be surgical, endovascular, or hybrid, based on the patient's conditions and aneurysm's anatomical features.

Long-term follow-up of adventitial cyst surgical excision in external iliac vein

Adventitial cystic disease of the venous system is an extremely rare condition. Forty-five cases have been described in the literature during the last 70 years, but they may not be representative of the real incidence of this pathologic process. We report a case of an adventitial cyst compressing the right external iliac vein and presenting with edema of the ipsilateral leg. Ultrasound imaging and computed tomography angiography showed the typical features of cystic disease and venous stenosis. Cyst excision was performed with a double surgical access. No perioperative complications were reported. There was no recurrence at 4-year follow-up.

Horseshoe Kidney Protection with Histidine-Tryptophan-Ketoglutarate Solution during Surgical Abdominal Aortic Aneurysm Repair

CASE REPORT

We report an unusual case of a 65-year-old male patient with horseshoe kidney, who underwent a successful open repair for an abdominal aortic aneurysm (AAA). The accessory renal arteries were perfused with histidine-tryptophan-ketoglutarate (HTK) solution (Custodiol®; Dr. Franz-Kohler Chemie GmbH, Bensheim, Germany) during the vascular reconstruction. There were no creatinine and estimated glomerular filtration rate (eGFR) modifications in the postoperative time. In the literature, only two cases of Custodiol solution for kidney protection during aortic surgery are reported. To the best of our knowledge, this is the first case of Custodiol perfusion for horseshoe kidney protection.

DISCUSSION

The concomitant presence of horseshoe kidney and an AAA requires a specific preoperative planning. This is necessary to define the appropriate surgical procedure and strategy. The onset of acute kidney injury is an aspect that must always be taken into consideration during aortic surgery, even more in the case we are reporting. Indeed, despite the complexity of the kidney anatomy, the use of Custodiol solution allowed a proper maintenance of the perioperative renal function, as shown by the postoperative levels of creatinine and eGFR.

CONCLUSIONS

Preoperative planning and organ preservation are crucial in AAA open repair, especially in the presence of congenital anomalies such as horseshoe kidney.

Endoanchors under 3D image fusion for a type IA endoleak after EVAR

The Heli-FX technique for type IA EL under 3D-IF proved to be accurate in terms of EL channel vision and correct endoanchors deployment. The EL volume rendering constant view allowed a precise anchors fixation at the EL channel. 3D-IF confirmed to be a valid help in orientation and navigation during endovascular aortic procedure.

Cerebrovascular Insufficiency from Radiation-Induced Progressive Obstruction of Supra-Aortic Vessels

BACKGROUND

Radiation therapy may accelerate atherosclerosis with progressive stenosis and occlusions of supra-aortic trunks.

METHODS AND RESULTS

We report the case of a 44-year-old woman with radiation-induced occlusion of the supra-aortic trunks presenting with recurrent cerebrovascular insufficiency after an unusual surgical revascularization technique (retrograde femoral-axillary bypass) performed for late failure of previous endovascular treatment.

CONCLUSIONS

Customized surgical procedure can be considered as a bailout to improve cerebral blood inflow in selected cases.

The potential role of quantitative digital subtraction angiography in evaluating type B chronic aortic dissection during TEVAR: preliminary results

OBJECTIVE

To evaluate the role of quantitative digital subtraction angiography (Q-DSA) with parametric color coding (PCC) in assessing patients with type B chronic thoracic aortic dissection (TBCAD) during thoracic endovascular aortic repair (TEVAR) procedures.

PATIENTS AND METHODS

A total of 11 patients electively treated in our Department for a TBCAD were retrospectively enrolled. All cases were treated with TEVAR for false lumen aneurysm of the thoracic descending aorta. For digital subtraction angiography (DSA) series post-processing, a newly implemented PCC algorithm was used to turn consecutive two-dimensional images into a single color-coded picture (syngo iFLOW, Siemens AG, Forchheim, Germany). In consensus reading, two clinicians experienced in vascular imaging evaluated the DSA series in blinded assessment and compared them to the color-coded images. PCC was assessed for its accuracy in identifying the true and false lumen as well as whether it could provide improved visualization in pre-deployment stent grafting and the final evaluation of treatment.

RESULTS

PCC facilitated the visualization of the aortic dissection angioarchitecture in terms of contemporary true and false lumen vision in 81.8% of the cases. In 72.7% of the procedures, Q-DSA was estimated to improve aorta information assessment in terms of false lumen viewing, and it was possible to identify the proximal entry tear position in 45.4% of the cases. After stent graft deployment, in 72.7% of the cases (all 8 patients in which the aortic arch false lumen was visible in pre-treatment), Q-DSA confirmed the absence of early false lumen reperfusion.

CONCLUSIONS

Our results indicate that Q-DSA could be useful in the intraprocedural evaluation of patients with aortic dissection during TEVAR procedures without additional x-ray costs and contrast exposure.

Public health implications of a case of haemolytic-uraemic syndrome associated with a concomitant outbreak of mild gastroenteritis in a small rural community

The concomitant occurrence of a case of haemolytic-uraemic syndrome (HUS) and 62 cases of mild gastroenteritis in schools of a small rural community in southern Italy induced the health authorities to suspect a foodborne outbreak of shiga-toxin-producing Escherichia coli (STEC) infection. The schools were closed and the catering service involved was investigated. However, STEC were not isolated from the HUS case or from the 56 cases of gastroenteritis examined, and the HUS case and the outbreak of gastroenteritis were probably just coincidental. A retrospective cohort study failed to show any correlation with consumption of school meals and suggested that the outbreak probably started outside the school setting and then spread within the schools by person-to-person transmission. All the cases examined were negative for common enteric pathogens and the responsible agent for the cases of gastroenteritis was not identified. The concern raised in the small community by the occurrence of a severe case of HUS and the lack of a rapid epidemiological assessment excluding the occurrence of a STEC outbreak, turned an epidemic episode of mild gastroenteritis into a public health emergency with relevant socioeconomic consequences. Prompt intervention in outbreaks following timely and effective risk communication are crucial for taking the most appropriate control measures and avoiding the spread of fear and panic in the community.

Molecular characterisation of verocytotoxin-producing Escherichia coli of serogroup O111 from different countries

A collection of epidemiologically unrelated verocytotoxin (VT)-producing Escherichia coli (VTEC) strains of serogroup O111 isolated from human patients and cattle with diarrhoeal disease in five different countries were characterised by determination of their VT genotypes, the presence of other virulence factors such as the intimin-coding eae gene and the enterohaemorrhagic E. coli (EHEC) plasmid, and their antibiotic susceptibility patterns. The genetic relatedness among isolates was evaluated by genomic DNA fingerprinting techniques such as restriction fragment length polymorphism analysis of ribosomal RNA genes (ribotyping) and pulsed-field gel electrophoresis. The results indicated that the VTEC O111 examined belong to two distinct clonal lineages. The first group was constituted mainly of non-motile, eae-positive, EHEC plasmid-positive isolates from both man and cattle. The second lineage was represented by an O111:H2 epidemic strain, isolated during an outbreak of haemolytic uraemic syndrome in France and exhibiting an unusual combination of virulence factors: VT production and aggregative adhesion to HEp-2 cells associated with an enteroaggregative E. coli (EAEC) plasmid.

Enteroaggregative, Shiga toxin-producing Escherichia coli O111:H2 associated with an outbreak of hemolytic-uremic syndrome

Shiga toxin-producing Escherichia coli O111:H2 strains from an outbreak of hemolytic-uremic syndrome showed aggregative adhesion to HEp-2 cells and harbored large plasmids which hybridized with the enteroaggregative E. coli probe PCVD432. These strains present a novel combination of virulence factors and might be as pathogenic to humans as the classic enterohemorrhagic E. coli.

Group B streptococci persist inside macrophages

Group B streptococci (GBS) are an important cause of neonatal sepsis, pneumonia and meningitis. In the early phase of infection, macrophages and polymorphonuclear cells (PMN) are the first immune cells that interact with GBS. In this in vitro study, to gain insight into GBS-macrophage interaction in the absence of type-specific antibodies, we examined the features of GBS survival in thioglycollate-elicited murine peritoneal macrophages and the effect of GBS on the protein kinase C (PKC)-dependent transduction pathway. Our results demonstrate that type Ia GBS, strain 090 (GBS-Ia) and type III GBS strain COH 31r/s (GBS-III), after in vitro phagocytosis survive and persist intracellularly in macrophages for up to 24 and 48 hr, respectively. However, macrophage activation by interferon-gamma (IFN-gamma) and lipopolysaccharide from Escherichia coli (LPS) caused a significant reduction in the time of intracellular persistence. Macrophage activation by IFN-gamma and LPS seems to be a multifactorial event involving multiple intracellular signal pathways also including PKC. Since PKC is one of the components in the signal network leading to macrophage activation and an important target for several intracellular micro-organisms, we wondered whether PKC could have a role in intracellular GBS survival. Both PKC depletion by treatment with phorbol 12-myristate 13-acetate (PMA) for 18 hr and PKC inhibition by Calphostin C rendered macrophages more permissive for the intracellular GBS survival. Furthermore, GBS-infected macrophages were unable to respond to PMA and LPS, activators of PKC, by inducing antimicrobial activity. The ability of GBS to impair PKC-dependent cell signalling was also demonstrated by the reduced c-fos gene expression in GBS-infected macrophages with respect to control macrophages, after LPS stimulation. In conclusion, our results indicate that GBS survive in macrophages and impairment of PKC signal transduction contributes to their intracellular survival.

Characteristics of Escherichia coli strains belonging to enteropathogenic E. coli serogroups isolated in Italy from children with diarrhea

Fifty-five Escherichia coli strains belonging to enteropathogenic E. coli (EPEC) serogroups were examined for phenotypic and genetic factors associated with virulence. The strains were isolated in Italy from children with diarrhea and identified as EPEC by clinical laboratories using commercially available antisera. O:H serotyping showed that 35 strains (27 of O26, O111, and O128 serogroups) belonged to 11 serotypes considered to be classical EPEC O:H serotypes. The other 20 isolates were classified as 15 nonclassical EPEC O:H serotypes. All the potential EPEC virulence factors associated with bacterial adhesion (localized adherence, fluorescentactin staining test positivity, presence of the attaching and effacing [eaeA] gene), the production of verotoxin, and the positivity with the enterohemorrhagic E. coli probe were significantly more frequent among isolates belonging to classical than nonclassical serotypes. Strains displaying an aggregative adhesion and hybridizing with the enteroaggregative DNA probe were found in serogroups O86, O111, and O126. Verotoxin-producing isolates belonged to serogroups O26, O111, and O128. Only one of the isolates hybridized with the EPEC adherence factor (EAF) probe, but 33 strains gave positive results with the eae probe, confirming that the former is more suitable in epidemiological studies in European countries. These results indicate that up to 75% of strains identified as EPEC by commercial antisera may possess potential virulence properties and/or belong to classical EPEC O:H serotypes and suggest that O grouping is still a useful diagnostic tool for presumptive identification of diarrheagenic E. coli in clinical laboratories.

Impaired detection of faecal verocytotoxin in the presence of Clostridium difficile cytotoxin in patients with haemolytic uraemic syndrome

Three cases of haemolytic uraemic syndrome associated with infection with verocytotoxin producing Escherichia coli are described. The concomitant presence of Clostridium difficile cytotoxin in the patients' stool impaired the detection of free faecal verocytotoxin. Stool specimens containing Clostridium difficile cytotoxin should thus be considered negative for verocytotoxin only after neutralisation of the Clostridium difficile cytotoxin with antitoxin.

Relationship between cytotoxic necrotizing factor production and serotype in hemolytic Escherichia coli

We examined the relationship between serotype and cytotoxic necrotizing factor (CNF) production in 123 hemolytic strains of Escherichia coli isolated from both stools and extraintestinal infections. Of 76 strains producing both hemolysin (Hly) and CNF, 66 (87%) belonged to one of six serogroups (O2, O4, O6, O22, O75, and O83). In contrast, 47 E. coli strains producing Hly only belonged to 21 different O serogroups, and only 2 of these (O6 and O18ac) were widely represented. Generally, CNF-positive and CNF-negative hemolytic isolates were assigned to different O serogroups, with the exception of O6, often present in both categories of isolates. Serogroups O4 and O18ac were significantly more prevalent among strains from extraintestinal infections than among those from stools. In contrast, the Hly-positive, CNF-negative isolates, belonging to numerous less common serogroups, were hardly ever isolated from extraintestinal infections. Serological typing further confirmed that hemolytic isolates of E. coli may grossly be divided into two main populations on the basis of the ability to produce CNF. Examination of hemolytic E. coli for this property may also be useful in achieving a more detailed characterization of pathogenic clones.