Abdominal Aortic Graft Infection Research Articles

The use of 99Tcm Sulesomab for the detection of infected abdominal aortic aneurysm grafts

The use of 99Tcm Sulesomab for the detection of infected abdominal aortic aneurysm grafts

Efficacy of long-term antibiotic suppressive therapy in proven or suspected infected abdominal aortic grafts

We have reviewed our experience of long-term antibiotic suppressive therapy in patients who underwent repair of an abdominal aortic aneurysm (AAA) and developed proven or strongly suspected infection of a graft. Five patients with abdominal aortic repair complicated by proven or suspected graft infections were treated with continuing antibiotic suppressive therapy based on microbiology culture reports. Two patients developed infection of an established graft, two patients had a graft inserted into an infected area and one patient was thought to be at high risk of developing infection of a recently placed graft. All patients had severe co-existent medical problems and were considered too ill to tolerate further definitive surgery. Response to therapy was monitored by absence of symptoms, fever, inflammatory markers and survival. All patients are alive with a median survival of 32 months, the longest having survived for 6 years. In selected patients with abdominal aortic graft infections, indefinite antibiotic suppressive therapy may be an acceptable alternative to further surgery.

Management of infected aortic grafts: development of less invasive surgery using cryopreserved homografts

Background. Aortic graft infection is associated with significant mortality and morbidity. Total graft replacement with homografts provides an effective treatment. Partial graft replacement at the site of infection may simplify the surgical procedure. Methods. Between January 1991 and December 1996, homografts were used in 18 patients (mean age, 61±12 years; range 41–85) with thoracic (4/18; 22%) or abdominal (14/18; 78%) aortic graft infection. Sepsis was present in 14 patients (78%); 6 (33%) had various aortic fistulae. Total graft replacement using homografts was performed in 14 (78%), and partial graft replacement at the site of infection in 4 patients (22%). Results. Hospital mortality was 11%. During the follow-up period of 22±15 months (range, 12–65) there was 1 infection and 1 homograft-related late death after complete homograft replacement, and 1 percutaneous vascular stent placement after partial graft replacement. No other instances of reinfection, suture line rupture or anastomotic aneurysms were observed. Conclusion. Total graft replacement with homografts provides an effective treatment for infected aortic grafts. Partial graft replacement at the site of infection is feasible and safe.

Mycotic aneurysm of arterial conduit presenting as massive upper gastrointestinal hemorrhage after liver transplantation

Mycotic aneurysm of arterial conduit presenting as massive upper gastrointestinal hemorrhage after liver transplantation

The Superficial Femoral Vein as Arterial Substitute in Infections of the Aortoiliac Region

In situ autogenous reconstruction is an alternative therapy for abdominal aortic prosthetic graft infection. We have used the superficial femoral vein (SFV) as an arterial substitute for proximal aortic anastomosis in seven patients. Six patients presented with aortic perigraft infections and one had a mycotic aneurysm of the infrarenal aorta with a primary aortoenteric fistula. There were no intraoperative but two postoperative deaths. During follow-up (mean: 19.8 months), one patient died at 5 months unrelated to his preceding vascular procedures; the others were doing well with patient SFV grafts 6-36 months after autogenous aortoiliac reconstruction. The SFV is a valuable donor vessel for autogenous reconstruction in the management of aortoiliac prosthetic graft infection. We explain both perioperative deaths in our treatment group with respect to the extent of the underlying infection and the virulence of the causative organism.

Management of abdominal aortic prosthetic graft infection requiring emergent treatment.

The purpose of this study was to investigate mortality and morbidity rates and long-term outcome of patients who underwent emergency treatment of abdominal aortic prosthetic graft infection. Between January 1984 and December 1993, 18 men aged fifty-nine +/- sixteen years were operated on as an emergency for an acute life-threatening complication of aortic prosthetic graft infection. The grafts had been implanted for abdominal aortic aneurysm in 9 patients and aortoiliac occlusive disease in 9, from one to one hundred seventy months previously. Five (28%) patients presented with a hemorrhagic shock due to a fistula between the vascular reconstruction and the small bowel (4 patients) or the right ureter (1 patient) and 13 (72%) had generalized sepsis. The grafts were always radically explanted. Extraanatomic revascularization procedures included 6 axillopopliteal and 12 axillofemoral bypass grafts. Operative mortality was 39% (7 patients), and 3 (9%) limbs were amputated within thirty days. Two (11%) patients died after seven and twelve months, respectively, of septic complications, and 1 (5%) patient died after six months from an unrelated cause. Eight (73%) patients are still alive at a mean follow-up of fifty +/- thirty-four months, but in 3 the extraanatomic bypass was removed for infection and 5 major amputations were performed. Two-year survival and limb salvage rates were 44% and 50%, respectively. Aortic prosthetic graft infections that require emergent treatment continue to demonstrate high early and late mortality and limb loss rates despite aggressive intervention and limb salvage procedures. Newer methods of managing these complications should continue to be investigated.

Bacterial and clinical criteria relating to the outcome of patients undergoing in situ replacement of infected abdominal aortic grafts

In a retrospective non-randomised study we assessed the outcome after in situ replacement of infected knitted Dacron abdominal aortic grafts in patients without septicaemia or retroperitoneal abscesses. We also assessed whether the specific bacterial infection influenced outcome. Over the 5 years studied, 18 patients (9 with perigraft infection and 9 with aortoenteric erosion) underwent in situ replacement of aortofemoral grafts. All patients were haemodynamically stable, none required emergency treatment. Preoperative assessment included CT, MRI, leukocyte-labelled scintigraphy, and bacterial cultures whenever possible. Infected grafts were totally excised and replaced in situ with standard PTFE prostheses. Bacterial diagnosis included intraoperative Gram-staining and postoperative graft cultures. None of the patients had retroperitoneal collections or proximal anastomotic dehiscence. All patients had 6 week intravenous antibiotic therapy. One patient died of myocardial infarction, and another of haemorrhagic shock from proximal anastomotic dehiscence, accounting for a graft-related mortality of 6%. Dehiscence resulted from a polymicrobial infection. Mean 37 month surveillance showed no amputations and no graft-related infections. In clinically and bacteriologically selected patients, total in situ replacement of infected abdominal aortic grafts offers an excellent outcome.

Diagnosis of abdominal aortic graft infection by a percutaneous intraluminal brushing of the graft

Diagnosis of abdominal aortic graft infection by a percutaneous intraluminal brushing of the graft

Infected Abdominal Aortic Grafts

Aortic grafts were inserted in 1711 patients at Ottawa Civic Hospital (OCH) between 1976 and 1986. Aorto-iliac occlusive disease was the indication in 884 while in 827, the graft was inserted for abdominal aortic aneurysms. Graft infection occurred in 12 patients; six presenting with gastrointestinal bleeding due to aorto-enteric fistula (AEF) and the other six presenting with groin abscesses, mostly as a draining sinus. These were treated with graft excision and immediate extra-anatomic bypass. Seven patients died, giving a mortality rate of 58%. Three surviving patients required above-knee amputation. These results are comparable to the results of others in the literature; therefore, continuing assessment of all aspects of graft infection and the search for more effective methods of prevention and management are needed.

Use of the Descending Thoracic Aorta as an Inflow Source in Aortoiliac Reconstruction: Indications and Long-Term Results

Bypass grafting from the descending thoracic aorta to the iliac or femoral artery is an underutilized procedure; fewer than 200 cases were reported in the past 30 years. Over the last decade we performed 32 bypasses to the femoral iliac or popliteal arteries using the descending thoracic aorta as the inflow source. In 19 (59%) patients the procedure was a primary aortic reconstruction, whereas in 13 (41%) it was secondary. The 30-day in-hospital mortality rate was 6.2%. Primary graft patency was 86% (+/- 7.8) at 2 years. To obtain a meaningful long-term patency analysis, we combined our experience with that reported in the literature during the same period. Follow-up data were available in 146 patients in whom the mean follow-up time ranged from 15 to 53 months. The operation was a secondary aortic reconstruction in 84 (58%) patients and was a primary procedure in 62 (42%). Reasons for the selection of the descending thoracic aorta as the inflow source included previous abdominal aortic graft failure in 56 (38%) patients, abdominal aortic graft infection in 26 (18%), unfavorable abdominal conditions in 30 (21%), and miscellaneous causes in 34 (23%). The 30-day in-hospital mortality rate for the collective experience was 5.5%. Life-table analysis of the collective primary graft patency rate was 88.3% (+/- 2.9) at 1 year, 81% (+/- 4.3) at 3 years, and 72.7% (+/- 8.5) at 6 years. Secondary graft patency for the collective experience was 93.1% (+/- 2.3) at 1 year, 88.2% (+/- 3.7) at 3 years, 82.7% (+/- 7.3) at 6 years, and 82.7% (+/- 10) at 8 years. Patient survival was 67.5% (+/- 6.9) at 5 years and 55.4% (+/- 9.9) at 7 years. These data suggest that bypass from the descending thoracic aorta to the iliac or femoral arteries offers low mortality and excellent durability and should be considered as the procedure of choice for secondary or extra-anatomic aortoiliac reconstruction.

Evaluation of muscle flaps in the treatment of infected aortic grafts

Standard therapy for abdominal aortic graft infection involving resection of the graft and extraanatomic bypass carries significant morbidity and mortality rates. The present study evaluates the feasibility of combining in situ graft replacement with a highly vascular tissue flap as an alternative to this problem. In 52 pigs a segment of a polytetrafluoroethylene graft was interposed in the infrarenal abdominal aorta. Staphylococcus aureus was used to infect the graft. One week later the animals were divided into six treatment groups. Group 1 (control) had debridement of the retroperitoneum only; group 2 had debridement with replacement of the graft; group 3 consisted of animals with the infected graft left in place and the graft wrapped with a rectus abdominis flap; group 4 is similar to group 3 except the seromuscularis of the jejunum was used to wrap the infected graft; in group 5 the graft was changed, and a rectus abdominis island flap was wrapped around the graft; and finally, group 6 was similar to group 5 except that the flap was obtained from the seromuscularis of the jejunum. Two weeks later, graft patency and infection status were assessed at reoperation. The incidence of graft infection was significantly reduced in groups 5 (0 of 10; p < 0.01) and 6 (1 of 10;p < 0.02) compared with group 1 (7 of 10), and the incidence of graft thrombosis was also greatly reduced in groups 5 (2 of 10) and 6 (1 of 10) versus group 1 (10 of 10;p < 0.01). Infection was also controlled in groups 3 (1 of 6) and 4 (2 of 6), but all grafts were thrombosed at reoperation. These results suggest that vascularized tissue flaps are effective in controlling the infectious process and thus may allow in situ replacement of infected abdominal aortic grafts.

In-situ replacement and extra-anatomic bypass for the treatment of infected abdominal aortic grafts

We reviewed the surgical results of 21 patients who had infected abdominal aortic grafts to determine the efficacy of in-situ graft replacement and extra-anatomic bypass in the management of these patients. Twelve patients had a primary perigraft infection, and nine had an infection secondary to an aortoenteric fistula (AEF). Whereas the infected graft was replaced with a new aortic prosthesis in 18 patients, an axillobifemoral bypass operation followed graft excision in three patients. Twelve of the graft replacement patients (two AEF patients) had a low-grade infection, with negative perigraft and blood cultures. All 12 patients were alive at a mean follow-up of 8 years. Two had required above-knee amputation because of severe occlusive disease, and one had required an axillobifemoral bypass because of reinfection. The remaining six graft replacement patients (five AEF patients) had severe graft infections, with positive perigraft fluid and blood cultures in which one or more bacteria were present. Five died of sepsis within 1 month of operation. The remaining patient, who later required an axillobifemoral bypass because of reinfection, was alive at follow-up 4.3 years after operation. The three patients (two AEF patients) who had axillobifemoral bypasses had severe graft infections, with positive perigraft fluid and blood cultures. They survived the extra-anatomic bypass operation and were alive at a mean follow-up of 4.5 years. We conclude that patients who have a low-grade graft infection and negative blood and perigraft cultures can be treated safely by graft excision and in-situ replacement with a new prosthesis.(ABSTRACT TRUNCATED AT 250 WORDS)

Anastomotic Tensile Strength Following In Situ Replacement of an Infected Abdominal Aortic Graft

The tensile strength and histologic features of anastomotic bonding were studied prior to and following in situ replacement of aortic vascular prostheses infected by Staphylococcus epidermidis. Sterile (n = 6) and infected (n = 19) Dacron grafts were used to replace the abdominal aorta of 25 dogs. After five weeks, grafts were explanted, and peak tensile force (measured in kilograms) required for anastomotic disruption was measured using a linear gain tensiometer. Anastomotic tensile strength (mean +/- SEM) of infected grafts (5.4 +/- 0.5 kg) was decreased when compared with that of sterile, control grafts (9.0 +/- 0.9 kg). The decreased anastomotic tensile strength of infected grafts was the result of an inflammatory aortitis adjacent to the suture line. Only grafts infected with the study strain of bacteria demonstrated signs of infection. In 19 dogs, the graft infection was treated by graft excision, antibiotic administration, and in situ graft replacement (Dacron or polytetrafluoroethylene prostheses). After five weeks and 12 weeks, anastomotic tensile strength of polytetrafluoroethylene (10.6 +/- 0.6 kg) and Dacron (10.8 +/- 0.5 kg) replacement grafts was similar to that of uninfected control grafts. In situ replacement of vascular prostheses infected by S epidermidis can result in graft healing with normal anastomotic bonding.

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

Conventional surgical wisdom dictates the complete removal of infected abdominal aortic graft, oversewing of the aorta, and restoration of lower limb bloodflow by extra-anatomic bypass grafting. Dissatisfied with this approach because of the high incidence of local complications, mortality, and loss of limb, 20 patients with secondary aortoduodenal fistula had duodenal repair, excision of the old graft, and placement of a new graft in the same location. A similar technique was used in three patients with erosion of an aortic graft into the jejunum. Length of follow-up averaged 5.2 years, and was more than 1 year in each instance. Of the eighteen patients who survived the repair, three have had early recurrent rupture or false aneurysm of the proximal aortic anastomosis, with consequent death in two, but fifteen patients (83%) have had no further related problem. There was no loss of limb. Use of greater omentum as a protective barrier seemed helpful. Optimal antibiotic usage, and the idea that varying degrees of graft infection require different approaches, require further definition. In conclusion, in situ graft replacement is the correct operative strategy in this challenging group of patients.

Surgical management of infected abdominal aortic grafts: Review of a 25-year experience

Eighty-four patients with infected abdominal aortic grafts managed from 1961 through February 1985 were reviewed. Thirty-three patients had associated aortoenteric fistula formation. Twenty-eight infections (33%) and 13 aortoenteric fistulas (39%) originated at The Cleveland Clinic, yielding an incidence of aortic graft infection of 0.77% (28 of 3652 grafts) and aortoenteric fistula formation of 0.36% (13 of 3652 grafts) at this center. Staphylococcus organisms alone or in combination with other organisms were isolated from 34% of the series. Management consisted of graft removal and extra-anatomic bypass in 54 patients (64%), graft removal alone in 14 (17%) patients, partial graft removal and extra-anatomic bypass in seven (8%) patients, and miscellaneous operations in nine (11%) patients. Twenty-three patients (27%) required major amputations, nine of which were bilateral. Life-table analysis yielded 30-day and 1-year survival rates of 72% and 42%, respectively. Thirty-day survival of the aortoenteric fistula subset (49%) was less than that (86%) of the nonaortoenteric fistula subset (p = 0.003). One-year survival of patients treated since 1980 (54%) was superior to that of patients treated before 1980 (31%, p = 0.035). No difference in operative or 1-year survival was demonstrated between the group treated with extra-anatomic bypass and subsequent graft removal and another in which both procedures were performed simultaneously, although the staged group experienced substantially fewer (p = 0.04) amputations (7%) than the combined group (41%).

Surgical management of infected abdominal aortic grafts: Review of a 25-year experience

Surgical management of infected abdominal aortic grafts: Review of a 25-year experience

The management of infected abdominal aortic grafts and graft-enteric fistulas.

Seven cases of infected aortic grafts or aorto-enteric fistulas following resection of an abdominal aortic aneurysm are reviewed. All cases were treated with axillo-femoral bypass and graft removal. Patients had recurrent fever, chills, and abdominal pain (5 patients), or massive gastrointestinal hemorrhage (2 patients). The two patients with massive gastrointestinal hemorrhage died. Three of the 5 long-term survivors had a recurrence of the retroperitoneal abscess after graft removal; one of these died. One axillo-femoral bypass graft required early thrombectomy. There have been no subsequent problems with any of the grafts in the 2.5 to 4 year followup period. Axillo-femoral bypass immediately before graft removal is the treatment of choice for infected or fistulous aortic grafts. Any delay in graft removal after the onset of symptoms should be avoided.

Rapid long tube intubation of the jejunum by a new endoscopic device

Despite the advantages of aseptic nonoperative intubation of the small intestine for decompression of obstructed loops, 48 per cent of the attempts lead to failure to pass the tube through the pylorus. The difficulty and inconvenience of passage beyond the stomach have been overcome by the development of a special tube attachment adapted to a fiberoptic duodenoscope (Olympus Model GIF-K). Under direct endoscopic vision the tube can be carried into the second and third portion of the duodenum, released from the scope, and then further prodded into the jejunum. The entire procedure takes less than 15 minutes. Rapid intubation has now been easily carried out in five patients. Three patients had mechanical bowel obstruction. Rapid and effective decompression allowed adequate time for stabilization of concomitant serious problems such as (1) marked cardiopulmonary dysfunction secondary to a near fatal pulmonary embolus, (2) severe peritonitis post appendectomy, and (3) acidosis and dehydration. Surgical correction of the obstructing lesions was safely deferred for up to one week until the concomitant problems improved. The fourth patient, who was a renal transplant recipient, had chronic gastric ileus secondary to duodenal ulcer. Rapid passage of the long tube into the jejunum allowed restoration of nutrition and avoidance of gastrostomy. The fifth patient, with an ileus secondary to an infected abdominal aortic graft, underwent successful decompression but died of sepsis. He represents the only mortality. We propose that jejunal intubation using our technic is not only rapid but relatively easy and should encourage the wider acceptance of aseptic long tube intestinal decompression.