Superficial Femoral Vein is Superior to Cryopreserved Allografts for in situ Aortic Reconstruction

Abstract

This is an important manuscript reporting the results of native aortic and aortic graft infections managed with cryopreserved aortic allografts in a large series of patients. The main finding is the relatively high graft-related complication rates of nearly 20% at a median follow-up of just over 1 year. Ten patients developed early graft complications, the most concerning being the four cases of allograft body disruption and two anastomotic disruptions, which brings into question the ability of the aortic graft to withstand the cryopreservation process while maintaining its inherent integrity to pulsatile aortic pressures. The four cases of midallograft rupture occurred in patients with more virulent Gram-negative infection or after the treatment of aortoenteric fistula, potentially higher risk groups. Notwithstanding this however, as the authors recognise in their discussion the high early graft-related complications as the main impediment to the use of cryopreserved allografts. They also recognise the concerns of late degenerative changes in both fresh and cryopreserved allografts. This series highlights the difficulties of obtaining robust long-term follow-up data in this patient cohort. These cases are rare and therefore the literature is littered with case reports and small series. This unit has a large aortic practice; their own prosthetic aortic graft infection rate was 1.4%, with over 40% of the cases described above having undergone their primary aortic procedures at other units. These patients have both high shortand medium-term mortality rates, the authors reporting 39% mortality at a median of just 12 months’ follow-up. A recent study of 25 patients, also from France, using cryopreserved allografts reported an in-hospital mortality rate of 48%. Longer-term mortality rates of 54% at 2.5 years in the USA have been reported in a contemporary series, which also highlighted the high in-hospital mortality rates associated with aorto-enteric fistulae. Both French series identified age and chronic renal impairment as poor prognostic factors, in keeping with many other vascular conditions. The usefulness of these poor prognostic indicators is debatable when the outcomes of conservative management of aortic graft infection are extremely poor. The authors have only included data on patients who underwent aortic reconstruction with allografts, and have not reported outcomes for patients who