Aortic Graft Infection Research Articles

Laparoscopic omental flap for the treatment of thoracic aortic graft infection: report of two cases and review of the literature

BackgroundThoracic aortic graft infection (TAGI) is a rare and serious complication after surgery for which the treatment is controversial and challenging. Rather than following the traditional surgical strategy of graft replacement and extensive debridement, we have chosen to preserve the graft and cover it by a laparoscopic omental flap. In this article, we describe the clinical manifestation, diagnostic modalities, and treatment of this disease and analyze the role of laparoscopic omental flaps in its treatment.Case presentationWe present two cases of thoracic aortic graft infections that had undergone surgical graft replacement for acute Stanford type A dissection. Their clinical manifestation of infection was atypical, with computed tomography suggesting infection of the grafts. Both patients were successfully treated with debridement, laparoscopic omental transposition, and antibiotics. The first case, a 55-year-old male, was found to have an infection at the aortic arch. The second case is a 52-year-old male who was found to have infection at the ascending aorta and arch. Surprisingly, both intraoperative cultures were negative. The infections were brought under control and the patients recovered steadily after surgery. Early follow-up results showed no signs of graft infection.ConclusionThese findings suggest that graft replacement for the treatment of TAGI is not always necessary in selected patients. Conservative surgical treatment, including laparoscopic omental transposition, is effective and less invasive for treating TAGI.

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

ObjectiveThe 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. MethodsA 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. ResultsDuring 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. ConclusionsThese 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.

Perigraft abscess after DeBakey type-1 aortic dissection: a case report

BackgroundPerigraft abscess is a rare condition which constitutes a small proportion of aortic graft infection (AGI). Early diagnosis is very important for timely intervention and improving the survival rate of patients because of its significant morbidity and mortality.Case presentationA 24-year-old young male patient with a history of complicated total arch replacement using elephant trunk technique for acute DeBakey type-1 aortic dissection 6 months before visited our hospital with the chief complaint of persistent fever. Antibiotic treatment in local hospital was ineffective. Echocardiography showed liquid dark area around the aortic graft, and a computerized tomography angiography (CTA) was done for further evaluation of periaortic fluid collection which showed findings to suggest perigraft abscess. The patient underwent surgical debridement of the abscess and was found to have an abscess around the aortic graft which was drained followed by antibiotic treatment. The patient was discharged to his local hospital and recovered well at 2 month follow-up appointment.ConclusionThis is a very rare case of aortic abscess around the graft that could successfully be managed by graft-conserving surgery, and it emphasizes the significance of early diagnosis of perigraft abscess in patients with aortic dissection surgery.

A Technical Tip of Aortic Stump Reinforcement with Plication of the Falciform Ligament of the Liver

The residual stump after excision of an infected aortic graft may be subject to acute disruption-blowout-because of recurrence of infection or fatigue due to the mechanical stress. We present an innovative technique in which we used the falciform ligament of the liver to reinforce the aortic stump. We excised the falciform ligament by giving attention to avoid any bleeding from the liver. The aortic stump was reinforced with synthetic, monofilament, nonabsorbable polypropylene sutures and the falciform ligament of the liver was plicated inside the stump and further sutured with polypropylene sutures. After 5months, he is in excellent condition. His laboratory examination is normal, he has stopped taking antibiotics, gained his initial weight, and recovered full activity. We presented an innovative technique in which we used the falciform ligament of the liver to reinforce the aortic stump after excision of an infected aortobiiliac synthetic graft. This technique can be an alternative option in patients with weak arterial wall or extended bacterial local infection in the retroperitoneal area which renders the aortic wall tissue extremely stiff to be folded and sutured. This technique may enhance the mechanical integrity of the stump.

SUN-185 Severe Hyponatremia and Type 4 Renal Tubular Acidosis (Functional Hypoaldosteronism) Secondary to Trimethoprim

Introduction:Trimethoprim-sulfamethoxazole (TMP-SMX) is a commonly used antibiotic. We present a case of severe hyponatremia and Type 4 renal tubular acidosis (functional hypoaldosteronism) in a patient treated with TMP-SMX.Clinical Case:A 62 year old gentleman with hypertension, dyslipidemia and a surgically repaired abdominal aortic aneurysm developed an aortic graft infection. He was admitted to hospital for acute right lower limb ischemia with embolic phenomena, and underwent surgical graft explantation. He required multiple courses of antibiotics post operatively.He was initially referred to Endocrinology for severe hyponatremia, deemed likely to be from a salt losing nephropathy secondary to polymyxin. Thyroid function and morning cortisol levels were normal. He was managed with intravenous hypertonic saline and oral salt tablets. The hyponatraemia resolved a week after polymyxin was stopped.Intravenous TMP-SMX was commenced the next day at 240 mg BD. A week later, the hyponatremia recurred, with concomitant hyperkalemia and a normal anion gap metabolic acidosis.The serum sodium was 126 mmol/L (reference interval (RI) 135-145) and the serum osmolality 275 mmol/kg (RI 275- 305). Urine studies showed a high urinary sodium (154 mmol/L) and osmolality (481 mmol/kg), consistent with renal salt wasting. The serum potassium rose to a peak of 6.1 mmol/L (RI 3.5 - 5.0), with a normal anion gap metabolic acidosis (bicarbonate 17 mmol/L (RI 21 – 31)). A paired urine pH of 8 pointed to an inability to acidify the urine.Given the clinical course and laboratory investigations, the diagnosis of TMP-associated hyponatremia and Type 4 RTA was made. Oral resonium was started to correct hyperkalemia, with a combination of oral sodium chloride and sodium bicarbonate used to treat the hyponatremia and metabolic acidosis. Fludrocortisone was not used given the concerns of causing hypertension in a patient with a diseased aortic graft.The dose of TMP-SMX was gradually reduced with improvement of the acid-base and electrolyte abnormalities, lending weight to our diagnosis. After the dose of the TMP-SMX was reduced to 80 mg BD, the hyperkalemia and metabolic acidosis resolved. The oral sodium chloride and sodium bicarbonate were gradually tailed off and stopped after cessation of the TMP-SMX.Clinical Lesson:Trimethoprim blocks the epithelial sodium channel (ENaC) of the principal cells in the terminal portion of the nephron, similar to potassium sparing diuretics like amiloride and triampterene. The resulting hyponatremia, hyperkalemia and metabolic acidosis can be life threatening. Therefore, monitoring of electrolytes and acid base status is important, particularly in susceptible patients or in those where a high dose of trimethoprim is required.

Management of thoracic aortic graft infections

Management of thoracic aortic graft infections

Choroidal Manifestation of Systemic Non-Tuberculous Mycobacterial Infection: A Case Series.

To describe choroidal findings associated with disseminated systemic non-mycobacterial infection. A retrospective observational case series included two patients (four eyes) with non-tuberculous mycobacterial disease. The activity of choroidal lesions was assessed by clinical examination, supported by colour fundus photography, fundus autofluorescence imaging, indocyanine green angiography, fluorescence angiography, and optical coherence tomography (OCT) angiography. The relationships between clinical symptomatology, choroidal findings, and systemic disease activity were evaluated. One subject diagnosed with aortic graft infection showed positive cultures for Mycobacterium chimaera. One HIV-positive subject showed a positive saliva culture for Mycobacterium avium. At presentation, all subjects showed chorioretinal manifestation. In one patient, the lesions were active and in the other patient, the lesions appeared inactive. With activity of disseminated chorioretinitis, the lesions had indistinct, blurred borders on fluorescence angiography and indocyanine green angiography and were hyporeflective with well-defined borders on OCT imaging. Multimodal imaging enables distinction between active and inactive lesions, thus supporting therapeutic management. Choroidal presentation of active disseminated mycobacterium infection indicates activity of systemic disease. Thus, even if the patient is not immunocompromised, an underlying systemic involvement should be ruled out.

Early and long-term results of open repair of inflammatory abdominal aortic aneurysms: Comparison with a propensity score-matched cohort

ObjectiveThe aim of our study was to compare early and long-term results of open repair of patients with inflammatory abdominal aortic aneurysm (IAAA) with matched cohort of patients with abdominal aortic aneurysm (AAA). MethodsThis retrospective single-center cohort study used prospectively collected data from an institutional registry from 1786 patients between 2009 and 2015. Patients with IAAA and AAA were matched by propensity score analysis controlling for demographics, baseline comorbidities, and AAA parameters in a 1:2 ratio. Patients were followed for 5 years. ResultsThere were 76 patients with IAAA and 152 patients with AAA. Patients with IAAA had more common intraoperative lesion of intraabdominal organs (P = .04), longer in-hospital (P = .035) and intensive care (P = .048) stays and a higher in-hospital mortality rate (P = .012). There were four patients (5.26%) with in-hospital lethal outcome in IAAA there were no deaths in the AAA group. During the follow-up, there was no difference in survival (χ2 = 0.07; DF = 1; P = .80) and overall aortic related complications (χ2 = 1.25; DF = 1; P = .26); however, aortic graft infection was more frequent in IAAA group (P = .04). ConclusionsOpen repair of IAAA is challenging and comparing to AAA carries a higher perioperative risk and long-term infection rate, even in high-volume centers. The main causes of complications are intraoperative injury of adjacent organs, bleeding, and coronary events. Patients with AAA in a matched cohort showed equal long-term survival, which should be assessed in bigger registries.

Azithromycin Exerts Bactericidal Activity and Enhances Innate Immune Mediated Killing of MDR Achromobacter xylosoxidans.

Azithromycin (AZM), the most commonly prescribed antibiotic in the United States, is thought to have no activity against multidrug-resistant Gram-negative pathogens such as Achromobacter xylosoxidans (AX) per standard minimum inhibitory concentration testing in cation-adjusted Mueller Hinton Broth. Here we provide the first report of AZM bactericidal activity against carbapenem-resistant isolates of AX, with a multifold decrease in minimum inhibitory concentration across 12 clinical isolates when examined under physiologic testing conditions that better recapitulate the in vivo human environment. This pharmaceutical activity, evident in eukaryotic tissue culture media, is associated with enhanced AZM intracellular penetration and synergistic killing with human whole blood, serum, and neutrophils. Additionally, AZM monotherapy inhibited preformed AX biofilm growth in a dose-dependent manner together with a reduction in viable bacteria. In an illustrative case, AZM in combination with piperacillin-tazobactam exerted clear therapeutic effects in a patient with carbapenem-resistant AX mediastinitis, sternal osteomyelitis, and aortic graft infection. Our study reinforces how current antimicrobial testing practices fail to recapitulate the host environment or host-pathogen interactions and may misleadingly declare complete resistance to useful agents, adversely affecting patient outcomes. We conclude that AZM merits further exploration in the treatment of drug-resistant AX infections. Novel approaches to antimicrobial susceptibility testing that better recapitulate the host environment should be considered, especially as infections caused by multidrug-resistant Gram-negative bacterial pathogens are expanding globally with high morbidity and mortality.

Treatment and Outcomes Of Aortic Graft Infections: A Single Center Experience

Treatment and Outcomes Of Aortic Graft Infections: A Single Center Experience

Systematic Review and Meta: Analysis of Aortic Graft Infections following Abdominal Aortic Aneurysm Repair.

Introduction. Aortic graft infection (AGI) is a rare complication following AAA repair and is associated with high morbidity and mortality. Management is variable, and there are no evidence-based guidelines. The aim of this study was to systematically review and analyse management options for AGI. Methods Data was collected between July and August 2018. A full HDAS search was conducted on the following databases: MEDLINE, EMBASE, CINAHL, and PUBMED. Meta-analysis was conducted using RevMan 5 software. Results 1,365 patient outcomes were assessed (10 cohort studies and 12 comparative studies). The most common treatment was in situ replacement of the graft (ISR) followed by extra-anatomical replacement (EAR). Various grafts were used for ISR, such as fresh/cryopreserved allograft, venous graft, and prosthetic grafts. No graft material was shown to be superior. Axillobifemoral graft was the commonest type of EAR used. In the majority of cohort studies, ISR was the main treatment for AGI. There was no significant difference in the overall mortality rate (ISR n = 70/176 vs. EAR n = 70/176 vs. EAR P = 0.87). Graft occlusion rate was significantly lower in the ISR group vs. the EAR group (n = 70/176 vs. EAR n = 70/176 vs. EAR P = 0.87). Graft occlusion rate was significantly lower in the ISR group vs. the EAR group (n = 70/176 vs. EAR n = 70/176 vs. EAR P = 0.87). Graft occlusion rate was significantly lower in the ISR group vs. the EAR group (Discussion. In situ replacement is the preferred method of treatment as it had lower rates of occlusion. Further strong evidence is required, such as a multicentre trial to establish a management pathway for the condition.

Laparoscopic Retroperitoneal Washout of an Infected Aorto-Bifemoral Graft: A Novel Technique

Aortic prosthesis infection is a challenging complication of aortic bypass surgery with high morbidity and mortality. We report a laparoscopic washout of an infected aorto-bifemoralperigraft collection with radiologic guidance using a nephroscope. The track was dilated with Endouro balloon and sheath to allow access. The cavity was copiously irrigated with saline and aqueous iodine solution. Surveillance computed tomography scan showed no new collection, thrombosis, aneurysm or fistula from the bypass graft. Bilateral lower limbs remained well perfused. Minimally invasive retroperitoneal washout may be a viable alternative to graft explant and extra-anatomical bypass in aortic graft infection.

Surgical treatment for secondary aortoesophageal fistula after prosthetic aortic replacement: A report of four cases

IntroductionWith the increase of thoracic aortic aneurysm surgery and thoracic endovascular aortic repair, secondary aortoesophageal fistula (AEF) has been reported. However, the treatment strategy for AEF remains controversial. Presentation of casesFour patients who had undergone prosthetic aortic replacement for thoracic aortic aneurysm 4–36 months previously, were hospitalized with sepsis-like symptoms. They were diagnosed with aortic prosthetic graft infection after computed tomography revealed ectopic gas around the prosthesis. After that, esophagogastroduodenoscopy revealed an esophageal perforation, so we diagnosed AEF. They received medication and stepwise surgery; 1 patient was discharged, 2 remain hospitalized, and 1 died. DiscussionSome reports have suggested that combined surgery provides better outcomes for AEF. Infection may be controlled by esophagectomy and antibiotic treatment, so prosthesis replacement is not always necessary. However, we should note that infection between a prosthetic graft and the native aorta brings a danger of pseudoaneurysm of the anastomosis. ConclusionBased on our experience we conclude that surgery performed stepwise along with infection control and general health improvement is a valid treatment strategy for secondary AEF after prosthetic aortic replacement.

Methicillin-resistant Staphylococcus aureus portends a poor prognosis after endovascular repair of mycotic aortic aneurysms and aortic graft infections

ObjectiveMycotic aortic aneurysms and aortic graft infections (aortic infections [AIs]) are rare but highly morbid conditions. Open surgical repair is the “gold standard” treatment, but endovascular repair (EVR) is increasingly being used in the management of AI because of the lower operative morbidity. Multiple organisms are associated with AI, and bacteriology may be an important indication of mortality. We describe the bacteriology and associated outcomes of a group of patients treated with an EVR-first approach for AI. MethodsAll patients who underwent EVR for native aortic or aortic graft infections between 2005 and 2016 were retrospectively reviewed. Primary end points were 30-day mortality and overall mortality. The primary exposure variable was bacteria species. Logistic regression analysis was used to determine association with mortality. Kaplan-Meier survival analysis was used to estimate survival. ResultsA total of 2038 EVRs were performed in 1989 unique and consecutive patients. Of those, 27 patients had undergone EVR for AI. Thirteen presented ruptured (48%). Eighteen (67%) were hemodynamically unstable. Ten had a gastrointestinal bleed (37%), whereas others presented with abdominal pain (33%), fever (22%), chest or back pain (18.5%), and hemothorax (3.7%). Twenty patients had a positive blood culture (74%), with the most common organism being methicillin-resistant Staphylococcus aureus (MRSA) isolated in 37% (10). Other organisms were Escherichia coli (3), Staphylococcus epidermidis (2), Streptococcus (2), Enterococcus faecalis (1), vancomycin-resistant Enterococcus (1), and Klebsiella (1). Thirteen patients had 4 to 6 weeks of postoperative antibiotic therapy, six of whom died after therapy. Fourteen were prescribed lifelong therapy; 10 died while receiving antibiotics. On univariate analysis for mortality, smoking history (P = .061) and aerodigestive bleeding on presentation (P = .109) approached significance, whereas MRSA infection (P = .001) was strongly associated with increased mortality. On multivariate analysis, MRSA remained a strong, independent predictor of mortality (adjusted odds ratio, 93.2; 95% confidence interval, 1.9-4643; P = .023). Overall 30-day mortality was 11%, all MRSA positive. At mean follow-up of 17.4 ± 28 months, overall mortality was 59%. Overall survival at 1 year, 3 years, and 5 years was 49%, 31%, and 23%. Kaplan-Meier survival analysis demonstrated that MRSA-positive patients had a significantly lower survival compared with other pathogens (1-year, 20% vs 71%; 5-year, 0% vs 44%; P = .0009). ConclusionsIn our series of AI, the most commonly isolated organism was MRSA. MRSA is highly virulent and is associated with increased mortality compared with all other organisms, regardless of treatment. Given our results, EVR for MRSA-positive AI was not a durable treatment option.

Autologous Superficial Femoral Vein for Replacement of Infected Aortic Prosthetic Graft

Introduction - Aortic prosthetic graft infection is one of the most severe complications in vascular surgery. In literature are reported good results of infected graft removal and reconstruction of aorto iliac/femoral segment with autologous superficial femoral vein (SFV) graft. Main goal of our study was to evaluate effectiveness and safety of this method in our center in the treatment of patients with aortic graft infection.

Utilization of Autologous Superficial Femoral Vein Graft in Cases of Infected Prosthetic Graft Replacement and High Infection-risk Cases

Introduction: Aortic prosthetic graft infection is one of the most severe complications in vascular surgery. There are two common scenarios - infection of already implanted graft and the prevention of graft infection in high-risk cases. In literature are reported good results of infected graft removal and reconstruction of aorto or iliac/femoral segment with autologous superficial femoral vein (SFV) graft. Main goal of our study was to evaluate efficiency and safety of this method for treatment of patients with aortic graft infection and in cases of patients with high prosthetic graft infection (e.g. with ischemic wounds). Methods: Between June 2007 and June 2018 we used autologous SFV graft for aorto iliac/femoral reconstruction in 64 cases (51 male and 13 female, average age 64.0 years with range from 30 to 79 years). In 33 cases was SFV graft used for replacement of infected prosthetic graft (13 aortobifemoral, 9 aortofemoral, 1 aortoaortic, 1 axillobifemoral, 3 replacement of one arm of aortobifemoral graft, 6 iliofemoral, 1 cross-over iliofemoral graft) and in 1 case replacement of infected stentgraft. In 29 cases was SFV graft used as a primary reconstruction in situations of high risk of graft infection (mycotic aneurysms, foot gangrene with highly virulent microbial findings, high CRP, fever). Results: Average follow-up time of our patients was 46.6 ± 33.0 months (range 1 - 127 months). 30-day mortality in our patient population was 6.3 % (4 patients died at 8th, 16th, 21st and 21st postoperative day). During the follow-up period more 26 patients died, but none of them in relation to SFV graft implantation, which remained patent in the time of dead. In one case (equal to 1.6 %) early re-intervention was required because of the graft failure. We observed one graft occlusion at 5th month. 5 patients (equal to 7.8 %) required high lower limb amputation till 3 months after the reconstruction, reason was the progression of peripheral arterial occlusive disease. We didn't observe any case of pulmonary embolism, infection recurrence, serious edema after SFV harvesting neither aneurysmatic dilatation of venous graft. In four cases (equal to 6.3 %) we observed temporary limb edema after SFV harvesting, but this situation was well controlled by compression stocking therapy. There was complicated wound healing after vein harvesting observed in 5 cases (equal to 7.8 %) and seroma in wound was observed in 3 cases (equal to 4.7 %). Conclusion: Our results support the use of SFV graft both in treatment of prosthetic graft infection in abdominal aortic region and for elective reconstructions in cases of patients with high risk of prosthetic graft infection. Comparing effectiveness and safety of SFV graft reconstruction with other methods speaks in favor of SFV grafting. Risk of infection recurrence is minimal, long-term patency is excellent and fear of serious limb edema after SFV harvesting is unjustified. Disclosure: Nothing to disclose

Durability and Infection Resistance of Cryopreserved Femoral Vein Allografts in Suprainguinal Position. A Single Center Study

Introduction - There is no consensus about the best treatment method of aortic graft infections (AGI) and primary arterial infections in aorto-iliac area. Cryopreserved arterial allografts have proved to be infection-resistant, but long-term durability is altered by late graft thrombosis and degeneration 1,2. However, cryopreserved big caliber venous allografts’ performance in aorto-iliac position is unknown. The aim of current study was to evaluate cryopreserved femoral vein allografts’ (CVA) safety, infection resistance and durability in suprainguinal setting in infectious conditions and compare their performance with cryopreserved arterial allografts (CAA) from the same homograftbank. Methods - Patients treated from February 2012 to March 2018 with cryopreserved allografts’ reconstruction due to infection encompassing suprainguinal area in a tertiary level hospital were retrospectively reviewed. Preoperative characteristics, indication for operation, operative details, early postoperative morbidity and mortality, late mortality, re-infections and graft re-interventions during the follow-up were recorded. Univariable analysis was done using crosstabs method, survival calculated with Kaplan-Meier method. Results - 31 patients underwent cryopreserved venous (femoral vein, n=21; cava vein, n=2) or arterial (superficial femoral artery, n=6; aorta, n=1; iliac artery, n=1) allograft reconstruction due to infection in aorto-iliac area. Indications for treatment were AGI in 14 (45%), mycotic aneurysm in 5 (16%), extra-anatomical prosthetic infection in 5 (16%), secondary arterial infection with rupture in 2 (6%), anastomotic pseudoaneurysm in 2 (6%) and aortic thrombosis with intestinal spillage in 1 (3%) case. 30-day and overall treatment-related mortality was 4 (13%). During the median follow-up of 15 month, two CAAs were treated due to thrombosis, two CVAs due to anastosmotic dilatation and one CVA due to re-infection and subsequent rupture making re-intervention incidence 16% (n=5). None of the grafts were lost and there were no amputations. At the end of follow-up 22 (71%) patients were alive. Kaplan-Meier estimation of survival was 87% (95% confidence interval, 81% to 93%) at 1 year and 63% (52% to 74%) at 2 years. Univariable analysis revealed no risk factors significantly associated with 30-day mortality, however cerebrovascular disease (p=0,028) was associated with treatment-related mortality and renal insufficiency (p=0,004) with overall total mortality. Due to small number of patients statistical analysis comparing CAA and CVA were unreliable, but two acute arterial occlusions call for caution and further research. Conclusion: Cryopreserved venous allografts appear safe, infection-resistant and durable reconstruction material in aorto-iliac axis based on single center experience and mid-term analysis. Further research is needed to compare their performance to cryopreserved arterial allografts and other biological reconstruction material.

Impact of a Multidisciplinary Management on the Outcome of Aortic (Endo)Graft Infections: A Retrospective, Single-Centre Experience

Introduction: Aortic (endo)graft infection is a rare (up to 5%) but devastating complication in vascular surgery, burdened by high mortality and reinfection rates. Aim of this study was to evaluate the impact of a multidisciplinary management on the outcome of the treatment of this complication in terms of morbidity and mortality. Methods: Since April 2011 a monthly meeting dedicated to infection of vascular substitutes was organised in our unit. Nuclear medicine physicians, infectious disease physicians, microbiologists, anesthesists and vascular surgeons discuss about the perioperative management of each patientin order to propose a tailored treatment strategy. Patients treated in our unit for aortic (endo)graft infection from January 2004 to July 2018 were retrospectively reviewed and divided in two groups: P1 (from 2004 to April 2011) and P2 (from April 2011 to 2018). Mortality and reinfection rates were the primary outcomes and were calculated using Kaplan-Meier curves, Log-Rank test was used to compare the two groups. Results: A total of 92 patients (87 males, mean age: 64 years old) have been included in the study: 31 in P1 and 61 in P2. Demographic and baseline disease characteristics were comparable between groups. Mean delay between index surgery and (endo)graft infection surgical treatment was 6 years. For each group, 21% of patients underwent an emergent surgical treatment. A conservative treatment was realised in 4 cases of P2. More total extractions (48% vs 51,7%) and reconstructions using cryopreserved allograft (0 vs 19%) were performed in P2. Mean follow-up was 4.9 and 1.2 years for P1 and P2 respectively. In-hospital mortality rate was 32.3% and 21.3% for P1 and P2 respectively. Median reinfection delay was 7.5 months. The reinfection rate was significantly reduced in P2 (47.6% vs 12.5%, log rank p=0.02). The 2-years survival rate was 54,6% and 69% for P1 and P2 respectively. Conclusion: A multidisciplinary management seems to provide better results in the management of aortic (endo)graft infections reducing in-hospital mortality and reinfection rates. Disclosure: Nothing to disclose

Cryopreserved Arterial Allografts for In-Situ Reconstruction of Abdominal Aortic Native or Secondary Graft Infection

Introduction - Native and aortic graft infection is rare but represents one of the most life-threatening complications in vascular surgery. The gold standard treatment includes excision of the infected aorta or graft and in-situ reconstruction using autologous veins, silver or antibiotic coated prosthesis, or cryopreserved arterial allografts (CAA). The optimal choice between these materials still remains debated. CAA has emerged as a good solution having the advantage of higher resistance to infection1,2 but also the disadvantages of potential degeneration and uncertain availability. Our aim was to evaluate the early and long-term outcome and identify predictors of mortality as regards cryopreserved arterial allografts used for in-situ reconstruction of abdominal aortic native or secondary graft infection. Methods - We retrospectively included 71 patients (mean-age: 65.2 years (range: 41-84, men: 91.5%) treated for abdominal aortic native or secondary graft infection (65 prosthetic graft infections, 16 of them had secondary aortoenteric fistula, 2 venous graft infections and 4 mycotic aneurysms) via in-situ reconstruction with CAA in two French University Hospitals, from 2001 to 2016. The cryopreservation protocol was identical in both centers (-140°C). Early (<30 days) and late (>30 days) mortality and morbidity, reinfection and CAA patency were assessed. A CT-scan was performed in all survivors. Survival was analyzed with the Kaplan-Meier method. Univariate analyses were performed with the log-rank tests and multivariate analysis with the Cox regression model. Results - Mean follow-up was 45 months (0-196). Early postoperative mortality rate was 14% (10/71). Early postoperative CAA-related mortality rate was 2.8% (2/71), both patients died from proximal anastomotic rupture on postoperative day 4 and 15. Early CAA-related reintervention rate was 5.6% (4/71), all had an anastomotic rupture and 2 were lethal. Early postoperative reintervention rate was 15.5% (11/71). Intraoperative bacteriologic samples were positive in 56.3% and 31% had a sole micro-organism. Escherichia coli was more frequently identified in the secondary aortoenteric fistula and Staphylococcus epidermidis in the infected prosthesis. Late CAA-related mortality rate was 2.8%: 1 septic shock at 2 months and 1 proximal anastomosis rupture at 1 year. Survival at 1, 3 and 5 years were 75%, 64% and 54%, respectively. Multivariate analysis identified type 1 diabetes (HR=2.49 [1.05–5.88]; P=0.04) and ASA (American Society of Anesthesiologists) score 4 (HR=2.65 [1.07–6.53], p=0.035) as predictors of mortality after in-situ CAA reconstruction. Reinfection rate was 4% (3/71). Late CAA-related reintervention rate was 12.7% (9/71): 1 proximal anastomotic rupture, 5 CAA branch stenosis/thrombosis, 1 ureteral-CAA branch fistula and 2 distal anastomosis false aneurysms. Primary patency at 1, 3 and 5 years were 100%, 93% and 93%, respectively. Assisted primary patency at 1, 3 and 5 years were 100%, 96% and 96%, respectively. No aneurysms or dilatation were observed. Conclusion - The prognosis of native or secondary aortic infections is poor. Aortic in-situ reconstruction with CAA offers acceptable early and late results. Patients with type 1 diabetes and ASA score 4 are at higher risk of mortality.

Visual Scoring Improves the Utility of 18F-FDG PET/CT in the Diagnosis of Aortic Graft Infection

Introduction - The diagnosis of aortic graft infection (AGI) is frequently complex. We aimed to assess the utility of 18F-FDG uptake (SUVmax ‘cutoff’ ≥3.8) or target-to-background ratio (TBR), plus visual scoring (Sah.B,EJVES;2015) in diagnosing AGI.