Aortic Sepsis Research Articles

An Unusual Late Complication of Axillobifemoral Bypass Graft: A Case Report

Axillobifemoral bypass is a well-established surgical procedure performed in conditions that preclude direct arterial reconstruction due to aortic sepsis, aortoenteric fistula, or other hostile abdominal pathology or prohibitive surgical risk. The choice of prosthetic graft used is either knitted Dacron(R) or polytetrafluoroethylene, with equally good results. Although externally supported grafts reportedly yielded improvement in primary patency compared to historical controls, no consensus exists as to which demonstrates superiority over the other despite several retrospective studies. Complications are usually limited to the perioperative period, although late anastomotic disruption, graft thrombosis, axillary thromboembolism, pseudoaneurysm formation due to seat belt trauma, and hemorrhage or graft rupture have all been described. In addition to the above complications responsible for graft failure, perigraft infection, intimal hyperplasia, poor distal runoff, anastomotic fibrosis, and comorbid conditions may contribute to graft failure. We describe an unusual late complication of an axillobifemoral bypass graft whereby an organized thrombus within the layers of the bypass graft led to luminal compromise and, hence, attenuation of flow and resultant "failing graft."

Axillofemoral grafting with externally supported polytetrafluoroethylene.

To evaluate the results of axillofemoral bypass grafting using externally supported polytetrafluoroethylene. Consecutive patients who were operated on by us from 1983 to the present were prospectively followed up in a vascular registry. The results of surgery with respect to morbidity and mortality, patency, limb salvage, and patient survival were determined by life-table methods. A standardized operative technique was used to perform 184 axillofemoral bypass procedures in 164 consecutive patients (age range, 14 to 90 years; mean age, 67 years; female, 33%). Follow-up ranged from 0 to 95 months (mean, 23 months). Ischemia was the indication for 83% of the procedures, and aortic sepsis was the indication for 16%. There were nine operative deaths (5%) and 17 major complications. Life-table primary patency, limb salvage, and survival rates at 5 years were 71%, 92%, and 52%, respectively. Indication for surgery, patency of the superficial femoral artery, and the performance of multilevel procedures did not significantly influence patency. The results of axillofemoral grafting using polytetrafluoroethylene are equivalent to those achieved with other accepted methods of treatment for lower extremity ischemia, including balloon angioplasty, aortofemoral bypass, and infrainguinal bypass. Axillofemoral bypass is an appropriate technique that is deserving of more widespread use.

Aortic sepsis: Is there a role for in situ graft reconstruction?

Conventional extraanatomic reconstruction for aortic sepsis is associated with a significant risk of operative death, as well as frequent late complications. We evaluated in situ aortic grafting in the treatment of primary or graft-related aortic infection. Eleven selected patients underwent in situ aortic graft reconstruction in the setting of mycotic aneurysm (n = 5), secondarily infected aortic aneurysm (n = 1), primary aortoenteric fistula (n = 1), and secondary aortoenteric fistula (n = 4). All patients survived: follow-up from 10 to 130 months reveals no evidence for graft thrombosis, pseudoaneurysm, new or recurrent aortoenteric fistula, or subsequent aortic operations in any patient. A literature review produced 110 cases of aortic sepsis managed by in situ aortic reconstruction during the last decade. Thirty-two patients (29%) either died in the operative period or suffered a lethal late complication associated with their aortic reconstruction. This mortality rate declined to 21% if patients undergoing incomplete removal of a contaminated graft were excluded, and to 19% with the addition of our 11 patients. Both our experience and that described in the literature suggest that, in properly-selected patients, in situ aortic graft replacement may be a rational treatment option for localized or circumscribed aortic sepsis.

Aortic sepsis: Is there a role for in situ graft reconstruction?

Conventional extraanatomic reconstruction for aortic sepsis is associated with a significant risk of operative death, as well as frequent late complications. We evaluated in situ aortic grafting in the treatment of primary or graft-related aortic infection. Eleven selected patients underwent in situ aortic graft reconstruction in the setting of mycotic aneurysm (n = 5), secondarily infected aortic aneurysm (n = 1), primary aortoenteric fistula (n = 1), and secondary aortoenteric fistula (n = 4). All patients survived: follow-up from 10 to 130 months reveals no evidence for graft thrombosis, pseudoaneurysm, new or recurrent aortoenteric fistula, or subsequent aortic operations in any patient. A literature review produced 110 cases of aortic sepsis managed by in situ aortic reconstruction during the last decade. Thirty-two patients (29%) either died in the operative period or suffered a lethal late complication associated with their aortic reconstruction. This mortality rate declined to 21% if patients undergoing incomplete removal of a contaminated graft were excluded, and to 19% with the addition of our 11 patients. Both our experience and that described in the literature suggest that, in properly-selected patients, in situ aortic graft replacement may be a rational treatment option for localized or circumscribed aortic sepsis.

Clinical results of axillobifemoral bypass using externally supported polytetrafluoroethylene

Seventy-six axillobifemoral grafts with externally supported polytetrafluoroethylene prostheses were performed since 1983. The indications for operation were absolute (aortic sepsis) in 20 (26%) patients and relative (excessive operative risk or technical difficulty) in 56 (74%) patients. The life-table primary patency for these operations at 4 years follow-up (mean follow-up, 2 years, 4 months) was 85%. We conclude that the patency results achieved in this patient series are sufficiently satisfactory to warrant use of axillobifemoral grafts in an expanded number of patients with high operative risk and need for bypass of aortoiliac occlusive disease.

Angiographically-Induced Infection of the Aorta

We present three cases of infection of the native aorta following angiography. The infection was an incidental finding at operation in two patients, whlle a third presented with fulminant sepsis. All had debridement of the retroperltoneum and underwent succetssful extraanatomic bypass. We feel caution is warranted in placlng a retropwitoneal graft even in suspected aortic sepsis. Prophylactic antlblotics may be advisable to protect agalnst Infection of atherosclerotic plaque during anglography.

Axillofemoral bypass: A tool with a limited role

Axillofemoral bypass (AXB) was performed on 100 patients who had claudication (19), pain at rest (42), gangrene or ulcer (22), aortic sepsis (14), or unresectable abdominal aneurysm (3). Unilateral (27 grafts), double unilateral (1), or axillobifemoral (72) grafts with Dacron (58), polytetrafluoroethylene (PTFE) (28), ring-supported Dacron or PTFE (12), or other material (2) were performed by 13 surgeons. Eight patients died within 30 days and three major amputations were necessary. Fifty-two (57%) of the 92 survivors had a total of 92 graft complications during a mean follow-up period of 21.5 months. Thirty-two patients underwent 57 reoperations of various types, incurring an additional three deaths and three amputations. Sixty (65%) of the original 92 survivors of AXB avoided reoperation. The 89 patients who survived the original and repeat procedures were followed up through the end of 1984 (62 patients), to late death (23), or to late graft removal (4), whichever occurred first. At these end points, 83 of the 89 (93%) patients had patent grafts. The graft patency rate of the original 100 AXBs by life table was 54% at 36 months; but with reoperation, it was 72%. Among those patients who left the hospital after AXB, the survival rate at 36 months was 69%. Statistically insignificant trends toward improved early patency were noted with bilateral femoral anastomoses, total iliac occlusion, and less severe ischemia. AXB provided safe palliation of severe arterial disease, with overall graft patency exceeding postoperative patient survival according to life-table analysis. However, the safety of AXB was tempered by frequent complications and the necessity for many reoperations to provide maximum efficacy. AXB should be limited to patients in whom aortic reconstruction is impossible or unduly hazardous or in whom only short-term symptom relief is necessary and should not be regarded simply as a low-risk substitute for aortofemoral bypass.

Omental Transposition for Closure of Median Sternotomy following Severe Mediastinal and Vascular Infection

Three patients suffering from severe sternal wound infection, underlying mediastinitis, and aortic sepsis were successfully treated by radical debridement of the infected tissues and mediastinal transposition of the greater omentum. Sternomediastinal antibiotic irrigation is an accepted treatment for postoperative sternomediastinitis, but appears insufficient when infection involves underlying vascular or cardiac structures. In such circumstances, extensive sternal debridement is mandatory and healthy tissue transposition, such as omentum, is a valuable alternative.

Regional thoracic societies

We present three cases of infection of the native aorta following angiography. The infection was an incidental finding at operation in two patients, whlle a third presented with fulminant sepsis. All had debridement of the retroperltoneum and underwent succetssful extraanatomic bypass. We feel caution is warranted in placlng a retropwitoneal graft even in suspected aortic sepsis. Prophylactic antlblotics may be advisable to protect agalnst Infection of atherosclerotic plaque during anglography.