Management Of Aortic Graft Infection Research Articles

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

Aortic graft infection 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 over 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 22 months, 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 aortic graft infection 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 aortic graft infection.

Management of aortic graft infection using biological neoaortic reconstruction: mid-term outcomes.

Management of aortic graft infection using biological neoaortic reconstruction: mid-term outcomes.

Added Value of Abnormal Lymph Nodes Detected with FDG-PET/CT in Suspected Vascular Graft Infection

Vascular graft and endograft infections (VGEI) cause a serious morbidity and mortality burden. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) imaging is frequently used in the diagnostic workup, but the additional value of abnormal (18F-FDG active and/or enlarged) locoregional lymph nodes is unknown. In this retrospective study, the additional diagnostic value of abnormal locoregional lymph nodes on 18F-FDG PET/CT imaging for VGEI was evaluated, including 54 patients with a culture-proven VGEI (defined according to the Management of Aortic Graft Infection [MAGIC] group classification) and 25 patients without VGEI. 18F-FDG PET/CT was qualitatively and quantitatively assessed for tracer uptake and pattern at the location of the vascular graft, and locoregional lymph node uptake and enlargement (>10 mm). 18F-FDG uptake intensity and pattern independently predicted the presence of VGEI by logistic regression (Χ2: 46.19, p < 0.001), with an OR of 7.38 (95% CI [1.65, 32.92], p = 0.009) and 18.32 (95% CI [3.95, 84.88], p < 0.001), respectively. Single visual assessment of abnormal locoregional lymph nodes predicted the presence of VGEI with a sensitivity of 35%, specificity of 96%, PPV of 95%, and NPV of 41%. The visual assessment of abnormal lymph nodes after qualitative assessment of 18F-FDG uptake intensity and pattern at the vascular graft location did not independently predict the presence of VGEI by logistic regression (Χ2: 3.60, p = 0.058; OR: 8.25, 95% CI [0.74, 63.37], p = 0.096). In conclusion, detection of abnormal locoregional lymph nodes on 18F-FDG PET/CT has a high specificity (96%) and PPV (95%) for VGEI. However, it did not add to currently used 18F-FDG PET/CT interpretation criteria.

Expanding the imaging armamentarium for the diagnosis of prosthetic aortic graft infection.

In their study published in this issue of the European Journal of Cardio-Thoracic Surgery, Tsuda et al. [1] evaluated the role of 18-fluorodeoxyglucose positron emission tomography (18-F-FDG PET) in the diagnosis of prosthetic aortic graft infection. Their retrospective review of 71 patients who underwent 18-FDG PET imaging after aortic repair showed that patients with aortic graft infection had a higher maximum standardized uptake value (SUVmax) than patients without infection (8.64 vs 3.40, P < 0.01) and that SUVmax value differed between the early postoperative period and long-term follow-up. The authors propose a cut-off value for SUVmax of 4.5 for suspicion of graft infection immediately after endovascular repair and subsequently using stepwise cuff-off values of 6.5 at 1 year, 5.5 at 3 years and 5.0 thereafter. Aortic graft infection is an uncommon complication, and its diagnosis and treatment can be challenging. The recent American Heart Association aortic disease guideline [2] provides recommendations for the diagnosis and management of prosthetic aortic graft infection. The diagnostic recommendations state that the sensitivity and specificity of diagnosis are enhanced by the use of cross-sectional imaging with computed tomography angiography combined with 18-FDG PET or magnetic resonance imaging of tagged white blood cells. Furthermore, the Management of Aortic Graft Infection Collaboration (MAGIC) group has proposed clinical/surgical, radiological, and laboratory diagnostic criteria for aortic graft infection, among which suspicious metabolic activity on 18-FDG PET is a minor criterion [3]. The MAGIC criteria were shown to have with good sensitivity and specificity in the prospective Vascular Graft Cohort study (VASGRA) [3]. Importantly, FDG-PET interpretation can be limited in patients with natural inflammation or malignancy that can affect its diagnostic accuracy for infection, as well as differences among centres and practitioners in their methods of image acquisition, processing and interpretation [4].

Percutaneous Drainage for Aortic Graft Infection Post-aneurysm Repair: A Viable Option?

PurposeNon-operative management of aortic graft infection is usually only considered in a palliative context. We describe the safety, efficacy, and clinical outcomes of percutaneous drainage of aortic graft infections (AGI) following either open or endovascular repair of aneurysmal disease.MethodsTwelve consecutive patients (11 males, 1 female, mean age 72.7 ± 10.3 years, age range 52-88 years) between January 2010-July 2020 who underwent percutaneous drain insertion in either an infected aortic sac or periaortic abscess cavity following endovascular or open surgical graft repair were identified. Patient and procedural characteristics as well as clinical outcomes were determined.ResultsOf the 12 patients who underwent percutaneous drain insertion, five (41.7%) had undergone open abdominal aneurysm repair, one (8.3%) open thoracoabdominal aneurysmal repair, and six (50%) endovascular abdominal aneurysm repairs. Drain size ranged from 10-20 French. All were inserted under ultrasound (US), computed tomography (CT), and/or fluoroscopic guidance. Median duration of drain placement was 55.2 days (range 3-174). Five patients (41.7%) had the drain in place as a stabilizing bridge until or after definitive surgical explantation and aortic reconstruction. Seven patients (58.3%) were managed with drain placement and antibiotic therapy without surgical intervention. Six (50%) were alive at the most recent time of follow-up (median, 732 days, range 166-1650 days). Three patients (25%) died during follow-up with causes including erosion of aortic reconstruction into sigmoid colon, unrelated chronic obstructive pulmonary disease exacerbation, and severe clostridium difficile colitis and pseudomonal pneumonia (median 1244 days, range 992-1597 days). Three (25%) patients were lost to follow-up. No drain-related complications were noted.ConclusionPercutaneous drainage of AGI following endovascular or open aneurysm repair is a safe and viable management option either as a temporizing measure as a bridge to surgical graft explantation or as a non-surgical therapy for long term management.

Primary lower-limb arterial stent infection managed with resection and In situ bovine pericardial revascularization

Peripheral arterial stent infection is a rare but morbid condition. We present the case of a patient with primary stent infection of his superficial femoral artery (SFA) and popliteal artery, managed with surgical explant and in situ reconstruction using rifampicin-soaked bovine pericardial tube graft. A 69-year-old man presented with a 3-day history of left groin pain. He had had stents placed into his SFA and popliteal artery in 6 months prior. Duplex ultrasound demonstrated a pseudoaneurysm of the common femoral artery (CFA), with ying-yang flow. A computed tomography angiogram confirmed this pseudoaneurysm, which had a thick rind of nonenhancing soft tissue. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. The patient was taken to the operating theater, and the CFA, profunda femoris artery, and SFA were exposed. After heparinization and clamp control, the pseudoaneurysm was incised, which revealed that the proximal SFA had been completely eroded. All infected tissues were resected. In situ arterial reconstruction was undertaken using a rifampicin-soaked bovine pericardium tube graft. A subsequent positron emission tomography scan revealed high fluorodeoxyglucose uptake around the patients remaining distal SFA and popliteal artery stents. These were explanted in the same manner described above. There is limited evidence regarding the prevention of infection when placing peripheral arterial stents. The Society of Interventional Radiology does not recommend routine prophylactic antibiotics when placing peripheral stents. In situ reconstruction using bovine pericardium is a well-described technique in the management of aortic graft infections, but there is limited experience in its use in a peripheral setting.

Outpatient parenteral antimicrobial therapy (OPAT) for aortic vascular graft infection; a five-year retrospective evaluation

ObjectivesAn estimated 1% of endovascular aneurysm repair (EVAR) devices become infected, carrying a high mortality rate. Surgical explantation is recommended and prognosis is guarded. This retrospective cohort analysis focuses on the role of outpatient parenteral antimicrobial therapy (OPAT) in the management of aortic vascular graft infections following EVAR.MethodsPatients who received OPAT for aortic graft infections (AGI) following EVAR from 2014 to 2018 inclusive were identified using the OPAT database. Clinical, microbiological and radiological data were collected. Survivors were followed up for a median of 36 months (range 25–60) after first presentation with infection. Outcomes were assessed.ResultsEleven cases with 20 OPAT episodes were identified: 10/11 male, median age 76 (IQR 71–81). Median time to presentation was 7 months (range 0–81 months) after EVAR. OPAT lead to a 55% reduction in length of hospital stay. One patient had graft explantation; four others had temporising measures. Eight of 11 were alive a median of 36 months after presentation with infection, having had a median of 2 re-treatments on OPAT (range 1–3). Seven of the eight survivors were on continuous suppressive oral antimicrobials; three were also intermittently on intravenous antibiotics for flares of infection. Patient/ infection outcomes were cure (1/11), improved (7/11), failure (3/11).ConclusionAGI following EVAR usually presents in the first year after graft deployment. OPAT has an important peri-operative role in patients suitable for curative surgery. OPAT followed by oral suppressive antimicrobial therapy can be a feasible long-term treatment for non-curative management of AGI. Survival in our cohort was longer than expected, and OPAT was feasible despite the complexity of these infections. OPAT can avoid multiple and lengthy hospital admissions and maximise time at home and quality of life in this cohort with life-limiting infection.

Novel prefabricated bovine pericardial grafts as alternate conduit for septic aortoiliac reconstruction

Infection of prosthetic aortic grafts represents a serious complication with high morbidity and mortality. Replacement with autologous material is recommended; however, in its absence, biological material should be favored. In the present retrospective cohort study, we evaluated the short- and midterm results with the use of commercially available prefabricated bovine pericardium grafts (BPGs) used for the management of aortic graft infection or aortic reconstructive surgery in the presence of systemic infection. We performed a retrospective analysis of patients in whom BPGs had been used for aortic reconstruction at two vascular centers. Prefabricated vascular pericardium grafts were preferred over other biological reconstruction techniques for selected cases. Comorbidities, procedure-related details, perioperative morbidity, clinical outcomes, and mortality were analyzed. From 2014 to 2019, 21 patients had received BPGs at two Austrian vascular centers. Their median age was 63years (interquartile range [IQR], 55-71years), the patients were predominantly male (76%), and the median body mass index was 25.3kg/m2 (IQR, 21.7-27.3kg/m2). The major comorbidities included arterial hypertension, peripheral artery disease, smoking, and chronic pulmonary disease. The indications for surgery were vascular graft or endograft infection in 62% and aortic reconstruction in the presence of systemic infection in 38%. Three patients (14%) had aortoenteric fistulas. Surgery was technically successful in all cases. The median follow-up was 21.6months (IQR, 6.0-34.6months). The 30-day mortality was 9.5%. The 1- and 2-year overall survival was 84% and 75%, respectively. Of the 21 patients, 89% had remained free of recurrent infection. One of the two reinfections had resolved after treatment of the underlying focus. At 2years, the primary and assisted primary patency rates were 86% and 94%, respectively. No limbs were lost during follow-up. Prefabricated BPGs represent a promising alternative for the management of aortic graft infections and aortoiliac reconstruction in the presence of systemic infection.

Systematic approach to diagnosis and management of infected prosthetic grafts in the proximal aorta.

ObjectivesManagement of infected prosthetic aortic grafts in the ascending and or root is complex and multifaceted. We report our diagnostic pathway, management and outcomes, identifying successful strategies.MethodsThis was a retrospective, single center, observational study. Consecutive patients who underwent management of infected aortic grafts in the ascending and/or root at our institution between October 1998 and December 2019 were included. The main outcome measures were: discharge from hospital alive with at least 1 year survival, operative mortality and success of primary treatment strategy.ResultsTwenty‐six patients presented with infection of proximal aortic grafts and were managed through a number of strategies with an overall hospital‐survival of 81% and 1 year survival of 69%. Twenty of them ultimately underwent redo surgery with 25% operative mortality (within 24 h of surgery). Five patients underwent washout and irrigation of which two were successfully treated and cured with adjunctive antibiotics and two went on to have staged explant and definitive surgery. Interval between surgery and infection was 42.5 ± 35.8 months. All patients had at least one major criterion and three minor criterions with no diagnostic uncertainty. The commonest primary strategy was 3a (definitive surgery), (13/26, 50%).ConclusionsAdopting a systematic and flexible patient specific approach to the diagnosis and management of patients with proximal aortic graft infections results in reasonable overall 1 year survival. In the majority of patients surgery is ultimately required in an attempt to achieve a curative treatment; however this comes with high operative mortality risk.

Aortic reconstruction in infected aortic pathology by femoral vein “neo-aorta”

The use of autologous femoral veins for in situ reconstruction of the aortoiliac segment is an effective technique to treat native aorta or prosthetic graft infections. The indications, technical details, and outcomes of this procedure are detailed. Graft infection involving the aortic segment, while rare, remains one of the most challenging vascular surgery conditions to treat. The original technique of "neo-aortoiliac surgery" with in situ autologous vein grafts has evolved over the past 25 years and remains a worthwhile alternative for the treatment of aortic graft infections, with lower mortality rates compared with other extra-anatomic or in situ surgical options. Acceptance of this surgical option is due to low graft re-infection rates, rare graft disruption, and low long-term aneurysmal degeneration. Excision of the femoral veins is associated with acceptable rates of lower limb edema. The use of an autologous femoral vein graft can be considered the standard of care in selected patients for the management of aortic graft infections. Optimal management of patients with aortic graft infections requires consideration of all potential therapeutic options because no single modality can be used, and individualizing treatment according to the clinical condition will yield the best patient outcomes.

The Cardioplastic Approach to the Treatment of Infected Aortic Grafts.

Aortic graft infection (AGI) is a rare complication following reconstructive aortic surgery, yet it represents a significant source of morbidity and mortality. There is no consensus regarding the optimal surgical management, due in part to the small cohorts of patient reports. Pedicled muscle or omental flap coverage of AGI has been shown to improve outcomes, making them a valuable consideration in the treatment algorithm. Thus, we aim to compile and evaluate cases of autologous vascularized tissue (AVT) in the treatment of infected aortic grafts, summarizing location specific trends, treatments, and outcomes. A comprehensive review of peer-reviewed literature regarding the management of AGI was performed. Data collected included patient characteristics, original procedure, pathogen, infection location, tissue utilized, technique of tissue isolation and delivery, staging, outcome, length of follow-up, and level of evidence. Ninety-four cases of AGI managed with AVT transfer were identified. Infection of ascending aorta grafts accounted for 59% of cases, followed by a combination of ascending aorta and aortic arch (21%), the descending thoracic aorta (18%), and the thoracoabdominal aorta (2%). The infected graft was preserved in 81% of cases, followed by debridement and AVT coverage. The omentum was the most commonly applied flap (69%) for all divisions of the aorta followed by the pectoralis major (19%), the rectus abdominis (5%), and latissimus dorsi (4%). Mortality was limited, and the Powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation overall survival was 93% (7 deaths), with a mean follow-up of 33.5 months. Autologous vascularized tissue coverage has proven to be a successful approach for treatment of infected aortic grafts. Although the incidence of AGI is rare, it represents an area of scarce evidence-based literature that warrants increased attention and surgical refinement. These results, which show a remarkably low infection-related mortality rate (3%), should encourage interdisciplinary collaboration with the plastic surgeon, cardiothoracic surgeon, and infectious disease specialists with the goal of improving outcomes in the treatment of infected aortic grafts.

Current management of infected aortic grafts in patients with connective tissue disorders

Patients with connective tissue disorder present a particular clinical challenge in the treatment of aortic graft infections. Specific complexities arise in patients with connective tissue disorders when reoperation for aortic graft infection is required. Herein we describe current management of infected aortic grafts in patients with connective tissue disorders using homograft and rifampin-coated graft replacements using in situ replacement therapy, which is associated with improved outcome compared to graft excision and extra-anatomic bypass.

Diagnosis of Aortic Graft Infection: A Case Definition by the Management of Aortic Graft Infection Collaboration (MAGIC)

The management of aortic graft infection (AGI) is highly complex and in the absence of a universally accepted case definition and evidence-based guidelines, clinical approaches and outcomes vary widely. The objective was to define precise criteria for diagnosing AGI. A process of expert review and consensus, involving formal collaboration between vascular surgeons, infection specialists, and radiologists from several English National Health Service hospital Trusts with large vascular services (Management of Aortic Graft Infection Collaboration [MAGIC]), produced the definition. Diagnostic criteria from three categories were classified as major or minor. It is proposed that AGI should be suspected if a single major criterion or two or more minor criteria from different categories are present. AGI is diagnosed if there is one major plus any criterion (major or minor) from another category. (i) Clinical/surgical major criteria comprise intraoperative identification of pus around a graft and situations where direct communication between the prosthesis and a nonsterile site exists, including fistulae, exposed grafts in open wounds, and deployment of an endovascular stent-graft into an infected field (e.g., mycotic aneurysm); minor criteria are localized AGI features or fever≥38°C, where AGI is the most likely cause. (ii) Radiological major criteria comprise increasing perigraft gas volume on serial computed tomography (CT) imaging or perigraft gas or fluid (≥7 weeks and ≥3 months, respectively) postimplantation; minor criteria include other CT features or evidence from alternative imaging techniques. (iii) Laboratory major criteria comprise isolation of microorganisms from percutaneous aspirates of perigraft fluid, explanted grafts, and other intraoperative specimens; minor criteria are positive blood cultures or elevated inflammatory indices with no alternative source. This AGI definition potentially offers a practical and consistent diagnostic standard, essential for comparing clinical management strategies, trial design, and developing evidence-based guidelines. It requires validation that is planned in a multicenter, clinical service database supported by the Vascular Society of Great Britain & Ireland.

Management of aortic graft infections - the present strategy and future perspectives.

Aortic graft infections (AGI) are serious complications of open and endovascular types of surgery with an incidence rate of 0.6-3 %. AGI are associated with 30-60 % perioperative mortality and 40-60 % morbidity rate with limb amputation rates between 10 % and 40 %. The economic cost of AGI is substantial. At the time of aortic reconstruction, almost 90 % of patients have one or more predisposing factors for AGI. The diagnosis is based on clinical symptomatology, laboratory markers, microbial cultures, and imaging modalities. The general principle of surgical treatment lies in the removal of infected graft, debridement of infected periprosthetic tissues, and vascular reconstruction by in situ or extra-anatomic bypass with long-term antibiotic therapy. The conservative treatment is used only for selected patients with endograft infection. This review summarizes the current knowledge about the incidence, predisposing factors, etiology, diagnosis, treatment options, and prevention of aortic vascular graft and endograft infections. With the growing number of endovascular procedures we can expect more cases of infected aortic endografts in patients with severe comorbidities in the near future, where the recent radical surgical approach (graft excision, debridement, and new revascularization) cannot be used. Therefore the less invasive, sophisticated and individualized treatment strategies will have to be used in search of the best therapeutic approach to each specific patient (Fig. 4, Ref. 82).

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

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

Contemporary management of infrarenal aortic graft infection: early and late results in 82 patients

Management of aortic graft infection (AGI) remains contentious. The purpose of this study was to evaluate factors of clinical significance which influence the outcome of different treatment modalities for AGI. From 2000 to 2008, 82 consecutive patients were treated for AGI. In situ reconstruction (ISR) was performed in 63 patients with various conduits, extra-anatomic reconstruction (EAR) in 11, conservative treatment in five and resection without reconstruction in three. The perioperative mortality rate for the series (33%) was similar for EAR and ISR and was higher in patients with secondary aortoenteric fistula (P < 0.001) in those undergoing emergency aortic reconstruction (P < 0.001) and in AGI caused by virulent organisms (P < 0.05). Fifteen (27%) of the surviving patients developed a recurrence of infection (RI). EAR patients were more exposed to RI (P < 0.04). In conclusion, ISR may be more appropriate for AGI, but this study cannot draw a conclusion relating to the optimal conduit for ISR.

Conservative Treatment of Aortic Graft Infection

Conservative, nonresectional management of aortic graft infections is the optimal management for selected patients with aortic graft infections. The best candidates are those patients who have significant comorbidities, or where the existing aortic graft is in a location that precludes excision without causing a high likelihood of morbidity and/or mortality, such as thoracoabdominal and aortic arch grafts. When considering the conservative approach, computed tomographic angiography, supplemented by Indium(111) leukocyte scanning, is the best combination of diagnostic tests. Contraindications to a conservative approach are infected anastomotic aneurysms, graft-enteric fistulas, and suture-line hemorrhage. Needle aspiration of perigraft fluid or phlegmon, under ultrasound or computed tomography guidance, is useful to both culture the infection and provide drainage. A conservative approach should not be considered when the graft infection is due to invasive Gram-negative organisms, such as Pseudomonas or Salmonella species. Once a conservative approach is selected as the best treatment option, drainage of an infected perigraft space is critical to success, and can be performed either percutaneously or with open surgery, whether an endograft or surgically placed graft is in place. If open drainage is required, the perigraft space should be debrided and catheters placed for long-term antibiotic irrigation. With continuous antibiotic irrigation until the cultures are negative, followed by life-long oral antibiotics, there are multiple case reports and small series of long-term survivors. Whether the aortic graft infection is cured or controlled is debated, but outcomes for high-risk patients and those with grafts in critical vascular beds are often superior to a high-risk surgical graft resection.

Aortic Graft Complicated by a Corynebacterium Striatum Infection Due to Previous Type IV Thoraco Abdominal Aortic Aneurysm Repair

We report successful management of aortic graft infection without graft explanation or extra-anatomic bypass. A 61 year-old male who had undergone surgical repair of a type IV thoraco-abdominal aortic aneurysm presented with left flank pain and raised inflammatory markers following graft implantation. CT scanning revealed a left psoas fluid collection. Graft infection was diagnosed. A radio-guided drainage and conservative management, with irrigation drain placement was undertaken with preservation of the aortic graft. There was no evidence of recurrent infection after follow-up at 34 months. Aortic endograft infection may be managed by surgical or radio-guided drainage, antibiotic irrigation of the graft and systemic antibiotic therapy without graft removal.

Intra Vascular Ultra Sound: One More Tool to Diagnose Aorto-duodenal Fistula

The incidence of aorto-enteric fistula in the first 5 years after abdominal aortic replacement ranges from 0.3 to 2%. We present a clinical case in which all conventional diagnostic tools failed to demonstrate the aorto-enteric fistula. A 73 year-old male suffering intermittent episodes of melena without signs and symptoms of infection was repeatedly admitted at our institution. All conventional diagnostic tools failed to show the bleeding source. Precise diagnosis was obtained using intra vascular ultrasound (IVUS). IVUS allowed prompt diagnosis of the aorto-duodenal fistula and opened the way to its endovascular treatment.

Limitations in the Management of Aortic Graft Infections

The use of aortic allografts has emerged as a management option in patients with aortic graft infections. We present a patient with a history of Takayasu's disease whose aortic graft infection was controlled with replacement of the excised infected aortic graft with an allograft. However, the patient died 9 months later after the rupture of a large anastomotic aortic aneurysm. Our report emphasizes the limitations in the management of aortic graft infections in patients with extensive vascular disease such as Takayasu's disease. This is the result of difficulties in performing extra-anatomical bypass as well as a possibly increased risk of formation of anastomotic aneurysms in these patients.