Graft Infection Research Articles

Enhancing acute inflammatory and sepsis treatment: superiority of membrane receptor blockade.

Conditions such as acute pancreatitis, ulcerative colitis, delayed graft function and infections caused by a variety of microorganisms, including gram-positive and gram-negative organisms, increase the risk of sepsis and therefore mortality. Immune dysfunction is a characterization of sepsis, so timely and effective treatment strategies are needed. The conventional approaches, such as antibiotic-based treatments, face challenges such as antibiotic resistance, and cytokine-based treatments have shown limited efficacy. To address these limitations, a novel approach focusing on membrane receptors, the initiators of the inflammatory cascade, is proposed. Membrane receptors such as Toll-like receptors, interleukin-1 receptor, endothelial protein C receptor, μ-opioid receptor, triggering receptor expressed on myeloid cells 1, and G-protein coupled receptors play pivotal roles in the inflammatory response, offering opportunities for rapid regulation. Various membrane receptor blockade strategies have demonstrated efficacy in both preclinical and clinical studies. These membrane receptor blockades act as early stage inflammation modulators, providing faster responses compared to conventional therapies. Importantly, these blockers exhibit immunomodulatory capabilities without inducing complete immunosuppression. Finally, this review underscores the critical need for early intervention in acute inflammatory and infectious diseases, particularly those posing a risk of progressing to sepsis. And, exploring membrane receptor blockade as an adjunctive treatment for acute inflammatory and infectious diseases presents a promising avenue. These novel approaches, when combined with antibiotics, have the potential to enhance patient outcomes, particularly in conditions prone to sepsis, while minimizing risks associated with antibiotic resistance and immune suppression.

Lower extremity degloving soft tissue injuries: Patterns, treatment, and short-term Outcome in Sudan: A Sub-Saharan African setting

BackgroundDegloving soft tissue injury is among the most devastating trauma types, especially when involving the lower extremities. This study aims to identify degloving soft tissue injury (DSTI) Patterns, Treatment, and Short-term Outcomes. MethodsThis is a prospective, cross-sectional, hospital-based study of patients with DSTIs over six months. ResultsFifty-six patients with lower extremity DSTIs were included. The mean age of the patients was. 29.2 years.Males were predominant (71.4 %). The common site for DSTIs is the dorsum of the foot. Fourteen patients with degloving injury to the foot dorsum had open fractures with type 3 A Gustilo classification. Participants with MESS 1 did not have underlying fractures. Patients with higher MESS scores experienced a more severe form of injury. Most of the patients presented late to plastic surgery services. Definitive management offered to the patients includes secondary intention, direct closure, SSG, and loco-regional flap. The loco-regional flaps used were random fascia-cutaneous, sural, saphenous, Lateral gastrocnemius, and medial gastrocnemius. Thirty-nine of the participants had no complications following management. The complications encountered include Surgical site infection, wound dehiscence, and partial graft or flap loss. These complications were managed by local wound care and a local flap. More extended hospital stay was observed in patients with low revised trauma scores. ConclusionLower extremity DSTIs are common injuries in Sudan, and it is management is challenging. DSTIs with underlying fractures are the most common pattern of injury, with the dorsum of the foot being the most commonly affected part. A multidisciplinary approach is essential for management.

Bone-flap-harvest-related donor site morbidity in reconstructive jaw microsurgery: Retrospective analysis based on 220 patients over a ten-year period

Microsurgery is the gold standard for hard and soft tissue reconstruction in head and neck neoplasia and malformations. Fibular, iliac crest, and scapular free flaps are the main choices for reconstructive surgery of the jaws. Although widely described in the literature, no statistical comparison analysis of the donor site morbidity of these has been performed to our knowledge. Therefore, in this study, the medical records of patients who underwent microsurgical jaw reconstruction at the Maxillofacial Oncological Reconstructive Surgery Unit of Umberto I General Hospital in Rome between 2011 and 2021 were analysed retrospectively. Inclusion criteria were complete clinical and radiological records, microsurgical reconstruction harvesting one of the three flaps, and a minimum follow up of 12 months. Principal donor site complications were recorded and compared among the flaps. The data were analysed using IBM SPSS Statistics (28.0.1.1, IBM Corp). The study enrolled 220 patients: 103 with deep circumflex iliac artery (DCIA) flaps, 87 with fibular free flaps (FFF), and 30 with scapular bone flaps (SBF). The main DCIA donor site complications were dysaesthesia (13.6%), abdominal hernia (2.9%), dehiscence (1.9%), infection (1.9%), and anterior superior iliac spinal fracture (1.9%). Similarly, the main FFF complications were dehiscence (8%), skin graft necrosis (6.9%), infection (5.7%), and dysaesthesia (3.4%). Subcutaneous seroma occurred in 13.3% of SBF patients and dehiscence in 6.7%. Regional dysaesthesia occurred significantly (p < 0.05) more often in DCIA than FFF or SBF patients. Dehiscence was significantly (p < 0.05) more frequent in FFF than DCIA or SBF patients. All flaps were safe and associated with low donor site morbidity. The jaws should be reconstructed selecting the flap that best satisfies the reconstructive needs based on the patient’s clinical features.

Contemporary Experience of the Neo-Aortoiliac System (NAIS) Procedure: A Case Series with Review of the Literature

Aortic graft infection (AGI) is a life-threatening complication that can result in death, amputation, sepsis, aorto-enteric fistula, and pseudoaneurysm formation. After explantation of the infected graft, options for reconstruction include extra-anatomic bypass or in-line reconstruction using antibiotic-coated prosthetic graft, cryopreserved allograft, or a neo-aortoiliac system (NAIS) using autogenous femoral veins. While the NAIS procedure has shown promising results, there is relatively limited clinical experience due the magnitude and morbidity of the surgery. In this study, we reviewed our single-center experience using the NAIS procedure and performed a systematic review of the contemporary literature more than the past decade. A retrospective review was performed on all patients undergoing NAIS reconstruction with autogenous femoral vein conduits at a single institution from 2010 to 2022. Pubmed, Embase, and Cochrane Library databases were queried for studies published from 2012 to 2022 to identify those reporting on outcomes of patients undergoing the NAIS procedure. Outcome variables included early and late mortality, major complications including amputation, graft or conduit related complications, re-infection, and re-intervention. Additional variables collected include patient demographics, operative technique, and follow up. There were 14 patients included in our case series with 30-day mortality of 21%. At a mean follow up of 22months, complication rate was 64.3%, re-intervention rate was 14.3%, re-infection rate was 7.1%, and amputation rate was 7.1%. On review of the literature, 12 studies ultimately met criteria to be included in analysis with a combined total of 368 patients. Pooled averages included 30-day mortality of 9.0%, re-intervention rate of 20.5%, re-infection rate of 5.6%, and amputation rate of 6.5%. The NAIS procedure for management of AGI is a formidable procedure with significant early mortality and morbidity. This treatment should be considered in the context of other revascularization options for management of an AGI.

Endovascular Treatment of Mycotic Aortic and Iliac Aneurysms in a Tertiary Center: A 15-Year Experience

Abstract Objective This retrospective case series reports the 15-year experience of the endovascular management of mycotic aortic and iliac aneurysms (MAAs) at a tertiary referral center in the United Kingdom. Materials and Methods The patients were identified through advanced searches in picture archiving and communication system (PACS) and electronic patient records. Data were retrieved and recorded in a structured spreadsheet including demographic details, symptoms and comorbidities, endovascular techniques employed and graft types, as well as treatment outcomes including 30-day mortality, 1-, 3-, and 5-year survival, aneurysm resolution percentage, and rates of re-intervention and complications. Statistical Analysis Descriptive statistics summarized the demographic and clinical characteristics, presenting them as means for continuous variables and frequencies/percentages for categorical variables. Results Of the 15 included patients, 73.3% (11/15) and 26.7% (4/15) were males and females, respectively, with a mean age of 64 years. Imaging revealed diverse anatomical involvement, with MAA in the descending thoracic (6/15), suprarenal and juxtarenal (5/15), infrarenal (3/15), and common iliac arteries (1/15). The 30-day mortality rate was 6.7% (1/15), while 1-, 3-, and 5-year survival rates from time of initial intervention were 57.1% (8/14), 38.5% (5/13), and 30.8% (4/13), respectively, with 1 case only just having undergone 1-month follow-up (performed in July 2023). The average mycotic aneurysm size was 47 mm (range: 19–80 mm), of which 33.3% (5/15) presented with rupture. The average sac size reduction following treatment was 31%, with 5/15 cases demonstrating complete resolution. Four cases required re-intervention due to persistent endoleak, sac re-expansion secondary to delayed endoleak, or stent occlusion. Persistent or recurrent graft infection was observed in 53.3% (8/15) of cases. Two cases required surgical re-intervention for stent occlusion. Conclusion Our findings reinforce the role of endovascular interventions in MAA acute management, showcasing immediate survival benefits. Late complications and frequent re-interventions emphasize the importance of vigilant surveillance.

1004 Urgent Explant of Infected Aortic Stent Graft in a Patient with Kidney Transplant Using Biological Aortoiliac Reconstruction and a Temporary Axillo-Femoral Perfusion Shunt: 6-Year Follow-Up and Literature Review

Abstract Background Written consent obtained for case report. A 59-year-old male who was 3-months post-EVAR repair under immunosuppression for kidney transplantation and anti-retroviral HIV treatment presented to ED in 2017 with abdominal pain and fever. CTAP revealed pyelonephritis in renal allograft. Blood cultures were positive for staphylococcus epidermidis. PETCT showed high-intensity uptake around endograft. Urgent explant of endograft and insitu biological aorto-biiliac graft reconstruction with bench prepared bilateral long saphenous veins were performed. Results The predicted challenges were locating source of infection, immunosuppressed state, and allograft preservation. Dacron graft was used as temporary perfusion shunt (left axillary artery to right superficial femoral artery) for renal allograft on right external iliac vessels. Endograft was removed via rooftop incision with visceral rotation. Supra-celiac and supra-superior mesenteric artery clamping times were 15 and 35 minutes. The source of infection was from infected appendix proximal to graft with erosion of right external iliac artery resulting in appendectomy in the same operation. Following 12-weeks of OPAT antibiotic-therapy, repeat PETCT revealed low-grade uptake around aortic graft and inflammatory markers were back to baseline. At 6 years in 2023, patient remains clinically well with ∼20% allograft function. Maintaining kidney allograft perfusion in the setting of elective non-infected aortic graft explant was previously reported, but with ENROUTE system (Rasheed et al., 2018). Conclusions The satisfactory long-term outcomes discussed here demonstrated with MDT planning involving vascular surgery, infectious diseases, renal medicine and patient, explant of infected graft with insitu biological graft reconstruction in renal transplant patients presenting with complex aortic-graft infection is feasible.

Not Your Usual Exposure: Tuberculosis Contact Investigation Related to Contaminated Bone Allograft

Background: Mycobacterium tuberculosis transmission through contaminated bone allograft product is unusual and was first described in 2021 with a second outbreak in 2023. In July 2023, Michigan Medicine conducted contact tracing for healthcare personnel (HCP), patients, and visitors following exposure to an immunocompromised patient with surgical site infection and subsequent widely disseminated tuberculosis (bacteremia, pulmonary, lymphadenopathy) following spinal fusion with bone allograft in April 2023. The patient was in the emergency department, operating room (OR), and inpatient units for 9 days prior to initiation of Airborne Precautions (AP). Methods: Michigan Medicine is a 1,107 bed academic hospital. HCP are screened for tuberculosis with interferon-gamma release assay (IGRA) testing upon hire and following tuberculosis exposure. Exposure testing includes baseline IGRA testing and follow-up testing at 10-12 weeks post exposure. Exposure criteria for this investigation was defined as sharing room airspace with the tuberculosis patient prior to initiation of airborne precautions or Central Sterile Processing Department (CSPD) staff involved with instrument decontamination without the use of a respirator. Of note, universal masking with surgical masks was not required during this time for staff and patients/visitors, with the exception of CSPD and OR staff. Contact tracing was performed by Infection Prevention and Occupational Health Services managed all test results and conversions. Results: 176 employees from perioperative care areas (n=30), CSPD (n=7), OR (n=9) and inpatient units (n=130) were IGRA tested. Five employee conversions were identified: one surgeon, one circulating OR nurse, two CSPD decontamination staff, and one respiratory therapist. At time of detection, none of the conversions had evidence of active tuberculosis. Additionally, 46 patients and visitors were tested with zero conversions. HCP compliance with IGRA testing was initially 15% before engagement from hospital and unit leadership and human resources. With intervention, employee compliance reached 100%. Conclusion: Despite standard use of surgical masks for OR and CSPD staff, aerosolization of infected bone graft material played an important role in tuberculosis transmission during surgery and instrument cleaning. Respiratory therapy practices in the ICU setting likely also increased risk for pulmonary tuberculosis transmission. Achieving 100% HCP compliance for baseline and follow-up IGRA testing is challenging and requires engagement of both unit and hospital leadership and human resources to ensure all HCP are tested.

Long-term outcomes of TEVAR for thoracic aortic diseases: a retrospective single-center study

BackgroundThe outcomes of Thoracic Endovascular Aortic Repair (TEVAR) vary depending on thoracic aortic pathologies, comorbidities. This study presents our comprehensive endovascular experience, focusing on exploring the outcome in long term follow-up.MethodsFrom 2006 to 2018, we conducted TEVAR on 97 patients presenting with various aortic pathologies. This retrospective cohort study was designed primarily to assess graft durability and secondarily to evaluate mortality causes, complications, reinterventions, and the impact of comorbidities on survival using Kaplan-Meier and Cox regression analyses.ResultsThe most common indication was thoracic aortic aneurysm (n = 52). Ten patients had aortic arch variations and anomalies, and the bovine arch was observed in eight patients. Endoleaks were the main complications encountered, and 10 of 15 endoleaks were type I endoleaks. There were 18 reinterventions; the most of which was TEVAR (n = 5). The overall mortality was 20 patients, with TEVAR-related causes accounting for 12 of these deaths, including intracranial bleeding in three patients. Multivariant Cox regression revealed chronic renal diseases (OR = 11.73; 95% CI: 2.04–67.2; p = 0.006), previous cardiac operation (OR = 14.26; 95% CI: 1.59-127.36; p = 0.01), and chronic obstructive pulmonary diseases (OR = 7.82; 95% CI: 1.43–42.78; p = 0.001) to be independent risk factors for 10-year survival. There was no significant difference in the survival curves of the various aortic pathologies. In the follow-up period, two non-symptomatic intragraft thromboses and one graft infection were found.ConclusionComorbidities can increase the risk of TEVAR-related mortality without significantly impacting endoleak rates. TEVAR is effective for severe aortic pathologies, though long-term graft durability may be compromised by its thrombosis and infection.

Long-Term Results of Physician-Modified Endografts for the Treatment of Elective, Symptomatic, and Ruptured Juxtarenal Abdominal Aortic Aneurysms.

The objective of this study was to report long-term results of an ongoing physician-sponsored, investigational device exemption (IDE) pivotal clinical trial using physician-modified endovascular grafts (PMEGs) for the treatment of patients with juxtarenal aortic aneurysms. Data from a nonrandomized, prospective, consecutively enrolling IDE clinical trial were used. Data collection began on April 1, 2011, and data lock occurred on January 2, 2024, with outcomes analysis through December 31, 2023. Primary safety and effectiveness end points were used to measure treatment success. The safety end point was defined as the proportion of subjects who experienced a major adverse event within 30 days of the procedure. The effectiveness end point was the proportion of subjects who achieved treatment success. Treatment success required the following at 12 months: technical success, defined as successful delivery and deployment of a PMEG with preservation of intended branch vessels; and freedom from: type I and III endoleak, stent graft migration >10mm, aortic aneurysm sack enlargement >5mm, and aortic aneurysm rupture or open conversion. Over the 12-year study period, 228 patients were enrolled; 205 began the implant procedure, and 203 received PMEG. Thirteen patients withdrew prior to PMEG. Two withdrew (<1.0%) after failure to deploy due to tortuous iliac anatomy and are tracked as intent to treat, and a total of 24 withdrew after receiving the PMEG implant. Forty-four patients died during the study period. A total of 14 were deemed lost to follow-up. Fifty-nine completed the 5-year follow-up period, and 62 remain active in follow-up visits.Aneurysm anatomy, operative details, and lengths of stay were recorded and included: aneurysm diameter (mean, 67.5mm; range, 49-124mm), proximal seal zone length (mean, 41.6mm; range, 18.9-92.9mm), graft modification time (mean, 48.7min), procedure time (mean, 137.7min), fluoroscopy time (mean, 33.8min), contrast material use (mean, 93.0mL), estimated blood loss (mean, 118.8mL), length of hospital stay (mean, 3.7d), and intensive care unit length of stay (mean, 1.6d).A total of 575 fenestrations were created for 387 renal arteries, 181 superior mesenteric arteries (SMAs), and 7 celiac arteries. Renal arteries were in 96% of patients and included 410 renal artery stents in 203 patients. The SMA was stented as needed and included one patient with an SMA stent placed before the procedure, 19 during the procedure, and 2 patients who underwent stent placement after the procedure. There were no open conversions or device migrations and 1 partial explant due to late distal graft occlusion. Three ruptures (1.4%) were recorded on days 830, 1346, and 1460. There was 1 presumed graft infection at 750 days (<0.5%) treated with? Thirty-day all-cause mortality was 2.9% (6/204). One type Ia, 1 type Ib, and 7 type III endoleaks were identified during follow-up and treated with successful reintervention at the 1-year period. The overall rate of major adverse events at 30 days was 15% (29/194). Technical success was 93.7%, and overall treatment success was 82.6%. PMEG can be performed with low rates of long-term morbidity and mortality, confirming our early and midterm reports that endovascular repair with PMEG is safe, durable, and effective for managing patients with juxtarenal aortic aneurysms. While historically considered experimental, these results suggest that PMEG is a safe and durable option and should be considered for patients where off-the-shelf devices are not available.

Enterococcus-related vascular graft infection: A case series

ObjectivesWe aimed to assess the frequency, management, and burden of enterococcal-related vascular graft infection. Patients and methodsFrom 2008 to 2021, data regarding all episodes of vascular graft infections initially managed or secondarily referred to our referral center were prospectively collected. We described the history and management of the infection, depending on the type of prosthesis used. ResultsThe frequency of enterococcal-related vascular graft infections was 29/249 (12 %). Most of them were early infections (22/29, 76 %). Infections were polymicrobial (26/29, 90 %), mostly associated with Enterobacterales. Among patients with positive blood cultures, 7/8 (88 %) involved enterococci. Patients with enterococcal-related vascular graft infections were mainly (22/29, 76 %) treated with an association of antibiotics. Mortality and relapse occurred in 28 % and 7 % respectively of the cases. ConclusionsEnterococcal-related vascular graft infections occurred in patients with comorbidities, during the early period following surgery and were more frequent in cases of intra-cavitary prosthesis. Their potential virulence needs to be considered, especially in polymicrobial infections.

Prophylactic Antibiotic Use in Reconstruction of Nasal Mohs Defects.

To evaluate the effect of prophylactic antibiotics on outcomes and complications following surgical reconstructions of nasal Mohs defects in the outpatient setting. Retrospective cohort study. Single tertiary care center, July 2021 to June 2023. All adult patients who underwent reconstruction of nasal Mohs defects in an outpatient office setting were examined. Patient demographics, surgical details, prophylactic postprocedural antibiotic use, and postprocedural complications (infection, flap or graft necrosis, wound dehiscence) were collected. Outcomes and complications were compared between patients who received and did not receive prophylactic antibiotics using χ2, Kruskal-Wallis, and multivariable logistic regression. A total of 211 patients met inclusion criteria. A majority of reconstructions utilized a local flap (70%), followed by a skin or composite graft (22%), then an interpolated flap (8%). Over half of patients (55%) were prescribed prophylactic antibiotics. Postprocedural complications were documented in 16 patients (7.6%), including infection (3.3%) and flap or graft loss or necrosis (1.4%). The rate of complications did not differ based on receipt of antibiotics. The only factors independently associated with the development of complications were history of chemoradiation and reconstruction with skin or composite grafts. Prophylactic antibiotics after nasal Mohs reconstructions performed in the office setting were not associated with any differences in the rate of postprocedural complications, including surgical site infections.

Mediastinal transposition of the greater omentum for treatment of infected prostheses of the ascending aorta and aortic arch.

To evaluate the outcomes of transposition of the omentum into the mediastinum to support the replacement of infected aortic grafts or to cover infected aortic grafts that are not amenable for surgical replacement. All patients with thoracic aortic graft infections who underwent mediastinal transposition of the omentum at our institution between 2005 and 2023 were included in this study. Mediastinal transposition of the omentum was performed either after replacement of the infected graft ("curative concept") or solely as bailout procedure by wrapping the infected graft ("palliative concept"). The diagnosis, including computed tomography scans during follow-up, was made according to the criteria of the Management of Aortic Graft Infection Collaboration. The patient cohort consisted of 31 patients. Both in-hospital and one-year mortality were 0% (n = 0) for the curative concept (n = 9) compared to 23% (n = 5) and 41% (n = 9) for the palliative concept (n = 22), respectively. There was no graft infection-associated death or recurrence of infection after 3 years in the curative group. Survival was 52% at 3 years in the palliative group, with freedom of infection in 59% of the patients (n = 13). Transposition of the omentum and wrapping of the infected aortic prosthetic graft is a useful bailout strategy for patients who are ineligible for replacement of an infected aortic graft. However, mortality stays high. For radical treatment of aortic graft infections, it may prove an effective supportive therapy and represents an important tool in the armamentarium of cardiac surgeons.

Preoperative examination of inflammatory biomarkers in relation to the prognosis of postoperative complications after heart transplantation

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Semmelweis University Heart transplantation (HTX) is the definitive therapy for end-stage heart failure. Although complications have drastically decreased with modern immunosuppressive therapy, surgical and anesthetic techniques, significant complications such as graft failure, acute rejection or infection must still be expected. The purpose of the study is to examine cytokine pathways linked to inflammation from direct preoperative serum samples, which can serve as prognostic factors in relation to septic events and mortality in the early postoperative period. The study was conducted using the blood samples of 102 patients who underwent HTX. Blood samples were taken from the patients immediately before HTX. The amounts of a total of 32 cytokines and related proteins were determined using LEGENDplex assays. After that, we correlated the biomarker amounts determined in the serum samples with the end points we indicated. In patients undergoing HTX who developed septic events during postoperative intensive care, the preoperative MMP2 serum concentration was significantly higher compared to other patients undergoing HTX (n=23, p=0.04). Independent predictors of mortality in the intensive care unit (n=5) were preoperative MRP8/14 (AUC=0.8), NGAL (AUC=0.75), IGFBP-4 (AUC=0.73), cystatin C (AUC=0.7) and the MMP2 (AUC=0.74) serum concentrations. Patients transplanted from left ventricular mechanical circulatory support (LVAD) (n=11) were examined as a separate group, where early postoperative mortality was significantly higher (n=4, p=0.02), the independent predictor of which was the concentration of IGFBP-4 (p=0.04 , AUC=0.73). Based on our results, it can be said that the differences in the preoperative concentration of certain inflammatory biomarkers that can be measured in the serum show correlations with the postoperative septic events and mortality of patients undergoing HTX.

Indication and Outcome of Late Open Conversion after Abdominal Endovascular Aortic Repair

ObjectiveEndovascular aortic repair (EVAR) has become the standard of care for patients with infrarenal aortic aneurysms over the last two decades. Endograft technology and treatment of complications like endoleaks, graft migration or graft occlusion developed over time. However, sometimes open surgical conversion maybe required. Our aim was to analyze the indications, the technical aspects and outcomes in patients who underwent open conversion after EVAR with different types and generations of endografts. MethodsThis retrospective single-center study reviewed all patients who underwent EVAR from 2004 to 2020. Open surgical conversions > 1 month post EVAR were identified. Conversions for graft infection were excluded. Indications for conversion and operative technique were analyzed. Primary endpoint of the study was 30-day mortality. Secondary endpoints were re-interventions and follow up mortality. ResultsDuring 2004 and 2020, 443 consecutive EVARs were performed, and 28 patients required open surgical conversion, with an additional 3 referred from other hospitals (N=31). The median age was 75 (range 58-93); 94% were male. Conversion was performed after a median time of 55 months (range 16 - 209). Twenty patients underwent elective and 11 emergency conversion. Indications for open conversion were graft migration respectively disease progression with endoleak type Ia and/ or Ib in 52 % (16/31) and sac expansion due to endoleak type II in 26 % (8/31). Of the 31 patients, 17 (55%) had at least one previous endovascular re-intervention. All patients met the device-specific instructions for use for each implanted endograft.In-hospital intervention rate was 16 % (5/31). 30-day mortality rate was 3% (1/31) with one patient died due to multi-organ failure after rupture with complete endograft replacement. Five patients (16%) died during follow-up. Mid-term follow-up was 47.5 months (range 24 -203) with estimated cumulative survival rates of 97%, 89%, and 84%, at 1, 3, and 5 years, respectively. ConclusionLate open conversion remains a valuable treatment option and can be performed safely in elective and emergency setting with a low early mortality. Lifelong surveillance, and prompt intervention when necessary are essential in ensuring optimal outcomes after EVAR and preventing the need for emergent conversions.

Breaking barriers: supporting hematopoietic stem cell transplant program through collaborative radiation therapy service from a physically distant center

BackgroundTotal body irradiation (TBI) for hematopoietic stem cell transplant (HSCT) has certain distinct advantages, such as uniform dose distribution and lack of drug resistance, but it is not widely available in resource-constrained settings. To overcome the limitations of in-house radiotherapy services in hematology centers, we evaluated the feasibility of conducting HSCT programs in coordination with two physically distant centers using a reduced-intensity TBI protocol.MethodsThirty-two patients with a median age of 20.5 years were included in the study. Fifteen patients were diagnosed with aplastic anemia, 10 patients with acute myeloid leukemia (AML), 3 patients with acute lymphocytic leukemia (ALL), and 4 patients with other hematological conditions. Conditioning regimens used were fludarabine plus cyclophosphamide in 29 cases, fludarabine-cytarabine ATG in 2 cases, and busulfan plus fludarabine in 1 case. The TBI dose was 3 Gy in 28 cases and 2 Gy in 4 cases. Patients were followed monthly after TBI, and the major toxicities were recorded.ResultsThe median follow-up was 22 months. The most common acute complication was acute graft-versus-host disease (GVHD), which occurred in 15.6% of patients. The major late complications were chronic GVHD (9.3%), Cytomegalovirus (CMV) infection (34.3%), and CMV-induced secondary graft failure (6.2%). Seventy-five percent of patients were alive, 21.9% were dead, and 1 patient was lost to follow-up.ConclusionsHSCT based on TBI is feasible even if the center lacks a radiotherapy facility by coordinating with a remote radiotherapy facility. without compromising the patient's outcome.

Antibiotic Delivery via a Chitosan-Based Nanofibrous Coating of Prosthetic Grafts for Treatment of Vascular Graft Infections

Antibiotic Delivery via a Chitosan-Based Nanofibrous Coating of Prosthetic Grafts for Treatment of Vascular Graft Infections

Phage Therapy for Cardiac Implantable Electronic Devices and Vascular Grafts: A Targeted Literature Review.

Infections of cardiac implantable electronic devices (CIEDs) and vascular grafts are some of the most dreaded complications of these otherwise life-saving devices. Many of these infections are not responsive to conventional treatment, such as systemic antibiotics and surgical irrigation and debridement. Therefore, innovative strategies to prevent and manage these conditions are warranted. Among these, there is an increasing interest in phages as a therapeutical option. In this review, we aim to collect the available evidence for the clinical application of phage therapy for CIED and vascular graft infections through literature research. We found 17 studies for a total of 34 patients. Most of the indications were left ventricular assist device (LVAD) (n = 20) and vascular graft infections (n = 7). The bacteria most often encountered were Staphylococcus aureus (n = 18) and Pseudomonas aeruginosa (n = 16). Clinical improvements were observed in 21/34 (61.8%) patients, with microbiological eradication in 18/21 (85.7%) of them. In eight cases, an adverse event related to phage therapy was reported. Phage therapy is a promising option for difficult-to-treat CIED and vascular graft infections by means of an individualized approach. Clinical trials and expanded access programs for compassionate use are needed to further unveil the role of phage therapy in clinical application.

PROSTHETIC GRAFT INFECTION: WHEN ECHOCARDIOGRAPHY IS NOT ENOUGH!

Abstract A 68–year–old Caucasian male, post–Bentall procedure with a bioprosthetic valve following extensive aortic dissection involving the ascending aorta and aortic arch, presented to the Emergency Department with persistent fever for over a month. During his hospitalization, he experienced ventricular fibrillation in the setting of hypokalemia, successfully managed with Advanced Cardiovascular Life Support (ACLS) and DC shock, leading to the restoration of sinus rhythm. Subsequently, he was admitted to the Cardiovascular Intensive Care Unite. Blood tests revealed neutrophilic leukocytosis with elevated inflammatory markers, anemia, and a troponin curve consistent with myocardial injury in the context of sepsis and anemia. Echocardiography demonstrated a left ventricle of normal dimensions with globally depressed function (EF 45%), attributed to apical akinesia. The prosthetic valve was functioning normally, and there were no signs of endocarditic vegetations or pericardial involvement. A transesophageal echocardiogram confirmed the absence of vegetations. Given echocardiographic signs of myocardial ischemia, coronary angiography was performed, revealing a coronary circulation free from significant stenosis. Cultural exams showed positivity for Enterococcus faecalis. A PET–CT revealed the presence of radioisotope uptake around the vascular prosthesis situated in the aortic arch. An Infectious Disease specialist recommended antibiotic therapy with Piperacillin/Tazobactam and Teicoplanin. At the one–month follow–up, the patient remained asymptomatic, free from new febrile episodes. The follow–up echocardiogram indicated improved global systolic function, and inflammatory markers remained consistently negative. Repeat blood cultures were negative. This case illustrates a suspected endocarditis on a prosthetic valve where both transthoraci and transesophageal echocardiography yielded negative results. The use of PET–CT, on the other hand, revealed the presence of vascular graft infection, proving to be a valuable method in this clinical setting.

A Case of Open Graft Replacement for Abdominal Stent Graft Infection Caused by Cholecystitis

A Case of Open Graft Replacement for Abdominal Stent Graft Infection Caused by Cholecystitis

Characteristics and Outcome of Vascular Graft Infections: A Risk Factor and Survival Analysis.

Vascular graft infection (VGI) is a serious complication after implantation of arterial vascular grafts. Optimal surgical and pathogen-specific antimicrobial treatment regimens for VGI are largely unknown. We evaluated patients with arterial VGI according to onset, location, microbiological and imaging characteristics, and surgical and antimicrobial treatment and performed an outcome evaluation. Consecutive patients with VGI treated in 2 hospitals from 2010 through 2020 were retrospectively analyzed. Uniform definition criteria and standardized outcome evaluation were applied. Logistic regression was used for multiple analysis; survival analysis was performed with Kaplan-Meier analysis and a log-rank test. Seventy-eight patients with VGI were included: 30 early-onset cases (<8 weeks after graft implantation) and 48 late-onset cases, involving 49 aortic and 29 peripheral grafts. The median time from initial implantation to diagnosis of VGI was significantly longer in aortic than peripheral VGIs (363 vs 56 days, P = .018). Late-onset VGI (odds ratio [OR], 7.3; P = .005) and the presence of surgical site infection/complication (OR, 8.21; P = .006) were independent risk factors for treatment failure. Surgical site infection/complication was associated with a higher risk for early-onset VGI (OR, 3.13; P = .040). Longer infection-free survival was observed in cases where the infected graft was surgically removed (P = .037). This study underlines the importance of timely diagnosis of VGI and preventing surgical site infections/complications at graft implantation. It highlights the complexity of infection eradication, especially for late-onset infections, and the importance of adequate antimicrobial and surgical treatment.