Removal Of Infected Graft Research Articles

Candida associated infra-inguinal prosthetic vascular graft infection: A case report

Prosthetic vascular grafts (PVG) are artificial vascular materials used for revascularization in the treatment of vascular diseases. Due to increase in life expectancy, the number of individuals requiring PVGs is increasing and encountering the PVGI is also more frequent. We presented an interesting case operated because of infected graft in which Candida albicans grew. The patient had been operated twice for peripheral artery disease in another hospital before. We performed femoro-popliteal bypass by using great saphenous vein after removal of infected graft. In peripheric bypass surgery performed with PTFE (polytetrafluoroethylene) graft, growth of Candida albicans in graft material is a rare condition and this situation has a high mortality rate. In the patients with comorbidities and who will undergo redo-surgery, excessive care should be given in terms of graft infections.

Prophylactic muscle flaps in high-risk-for-poor-healing patients with prosthetic bypasses increases deep wound complications.

Incisional complications of groin after inflow or infrainguinal bypasses with prosthetic conduits can result in major morbidities that require reoperation, infected graft removal, and limb loss. Muscle flaps are typically performed to treat groin wound complications, but they are also done prophylactically at the time of index procedures in certain high-risk-for-poor-healing patients to mitigate anticipated groin wound complications. We used a nationwide multi-institutional database to investigate outcomes of prophylactic muscle flaps in high-risk patients who underwent prosthetic bypasses involving femoral anastomosis. We utilized ACS-NSQIP database 2005-2021 to identify all elective inflow and infrainguinal bypasses that involve femoral anastomoses. Only high-risk patients for poor incisional healing who underwent prosthetic conduit bypasses were selected. A 1:3 propensity-matching was performed to obtain two comparable studied groups between those with (FLAP) and without prophylactic muscle flaps (NOFLAP) based on demographics and comorbidities. 30-day postoperative outcomes were compared. Among 35,011 NOFLAP, 990 of them were propensity-matched to 330 FLAP. There was no significant difference in 30-day mortality, MACE, pulmonary, or renal complications. FLAP was associated with higher bleeding requiring transfusion, longer operative time, and longer hospital stay. FLAP also had higher overall wound complications (15.2% vs. 10.6%; p=0.03), especially deep incisional infection (4.9% vs. 2.4%; p=0.04). Prophylactic muscle flap for prosthetic bypasses involving femoral anastomosis in high-risk-for-poor-healing patients does not appear to mitigate 30-day wound complications. Caution should be exercised with this practice and more long-term data should be obtained to determine whether prophylactic flaps decrease the incidence of graft infection.

Clinical and Multimodal Imaging Findings in Disseminated Mycobacterium Chimaera

To characterize the ophthalmic clinical and multimodal imaging findings of disseminated Mycobacterium chimaera infection after cardiothoracic surgery. Observational case series. Four patients (8 eyes) with disseminated M.chimaera infection. Patients were evaluated with biomicroscopy, OCT and OCT angiography, fundus autofluorescence, and fluorescein and indocyanine green angiography. Clinical and multimodal imaging findings of patients with disseminated M.chimaera infection. All 4 patients were white men with a mean age of 65.5 years (range, 60-75 years) who had aortic valve or root infection, or both, with M.chimaera diagnosed by culture, gene sequencing, or both. All 4 patients demonstrated bilateral choroidal lesions on funduscopy and evidence of osteomyelitis by imaging, culture analysis, or both at the time of ocular diagnosis. Indocyanine green and OCT angiography revealed numerous additional subclinical choroidal lesions and were used to track disease response to therapy. Fluorescein angiography and fundus autofluorescence were useful in determining lesion age and activity. All patients were treated with 3- or 4-drug antimycobacterial therapy. Three underwent revision of cardiothoracic surgery with removal of infected graft. One patient went on to demonstrate progressive ocular disease that was noted before each of his surgical revisions. Two patients showed improvement in ocular and systemic disease, however one of them developed a choroidal neovascular membrane. The final patient was a single encounter whose clinical and imaging findings showed longstanding inactive disease. Ophthalmologists should be aware of the systemic and ocular findings of this rare life-threatening disease. Multimodal imaging is useful in corroborating a diagnosis of ocular M.chimaera andparticularly in evaluating patient response to therapy, because choroidal activity seems to mimic systemic activity. Treating physicians should be aware of the co-occurrence of choroiditis and osteomyelitis. Choroidalneovascular membrane can also be a late complication of this disease.

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).

FDG-PET in Prosthetic Graft Infections

Graft infection following prosthetic vascular reconstruction is an uncommon but severe complication. The clinical presentation is often subtle and nonspecific and may occur long after surgery. Although defining a prosthetic vascular graft infection can be difficult, early diagnosis and treatment are essential for the correct choice of treatment to prevent further complications as well as the high morbidity and mortality associated with repeat surgery and removal of infected grafts. False-positive results may lead to unnecessary surgery while failure to diagnose graft infection may have life-threatening sequels. Scarce literature that is currently available regarding the role of (18)F-labeled fluorodeoxyglucose imaging for assessment of vascular graft infection suggests that this modality may represent reliable noninvasive imaging modality in this specific clinical setting. PET/CT increases the test specificity and thus improves diagnostic accuracy. The precise anatomic localization of increased (18)F-labeled fluorodeoxyglucose PET/CT enables accurate differentiation between graft and adjacent soft tissue infection leading to more accurate diagnosis and subsequent optimized therapeutic strategy.

Management of prosthetic graft infection after lower limb arterial bypasses

To summarize the experience in management of prosthetic graft infection (PGI) after lower limb arterial bypasses and investigate optimal measures for prevention and treatment. Records of 15 cases of PGI between January 2004 and December 2009 were retrospectively analyzed, including 14 male and 1 female with the average age of 64.8 years (ranged from 40 to 84 years). PGI occurred from 5 d to 59 months (average 6.4 months) after the last reconstructive procedures with symptoms as follow: nonhealing wound with vascular graft exposure in 8 cases, persistent sinus related to vascular graft with purulent secretion in 5 cases and without secretion in 1 case, and ill-incorporated graft with peri-graft fluid in 1 case. Broad-spectrum antibiotics were administrated in all PGI cases. Surgical treatments included local debridement and drainage in 4 cases (one death from postoperative acute myocardial infarction), local debridement and skin flap rotation in one case, complete removal of the occluded infected grafts in 8 cases including major amputation in 3 cases, removal of patent infected graft and extra-anatomic bypass with silver-bonded Dacron vascular graft in 1 case, and partial removal of patent infected graft without reconstruction in 1 case with a re-canalized stent-graft. Limb salvage was achieved in 9 cases, and 4 cases received major amputation. One case was failed to follow-up and one died of postoperative acute myocardial infarction. Initially 13 patients were followed and 2 died during follow-up (because of colon carcinoma and intracranial hemorrhage respectively). Eleven patients were followed for 1 to 70 months (average 22.3 months) including 8 cases with limb salvage and 3 with major amputation. Accumulative mortality rate, amputation rate, and graft occlusion rate were 20% (3/15), 26.7% (4/15), and 53.3% (8/15) respectively. PGI after lower limb arterial bypasses is a devastating complication with high risk of graft occlusion and amputation. Removal of the infected grafts may be mandatory for most cases, but local management for patent infected grafts may be recommendable for selected cases.

Recurrent Aortoenteric Fistula

Aortoenteric fistula is a rare but often devastating cause of GI bleeding. It is most commonly the secondary type, when a previously placed abdominal aortic graft erodes into the distal duodenum causing a life threatening GI hemorrhage. Fatality is the rule unless it is recognized early and treated promptly. A recurrent aortoenteric fistula is exceedingly rare with only a handful of cases reported in the medical literature. A 64-year-old woman presented with hematemesis and melena. Medical history was remarkable for an abdominal aortic aneurysm s/p uncomplicated elective graft repair in 1993 with subsequent development of an aortoduodenal fistula in 2000 manifested as severe GI bleeding. This was managed at our institution with emergent surgery (infected graft removal, over-sewing of the aorta, and creation of a axillary-femoral artery bypass) with full recovery. On physical exam the patient appeared comfortable. She was orthostatic and had a clean vertical abdominal scar without a pulsatile mass. Abdomen was soft and not-tender. Emergent EGD utilizing a pediatric colonoscope revealed a significant amount of non-adherent blood clots in the descending duodenum without active bleeding. No lesions or active bleeding sites were identified on the examination. A CT scan and technetium 99m pertechnetate tagged RBC scan revealed active bleeding in the distal duodenum adjacent to an aneurysmal abdominal aortic stump. Emergent laparotomy revealed a large aortic stump pseudoaneurysm with a pin size hole communicating with the distal duodenum. The pseudoaneurysm and duodenum were repaired and the fistulous communication was excised. An omentoplasty was performed in order to buffer the separation between the aortic stump and duodenum. The patient had an uneventful post-operative course and was discharged to a rehabilitation facility twelve days later. This most unusual case highlights the importance of recognizing the clinical presentation of an aortoenteric fistula and how it is an infrequent but often lethal cause of severe GI bleeding. Moreover, although such cases are quite rare, it does not preclude its recurrence. One must approach each patient with severe GI tract bleeding with a broad differential diagnosis keeping in mind both their current risk factors as well as their past history.

SURGICAL INFECTIONS IN PATIENTS WITH CHRONIC RENAL FAILURE

Patients with chronic renal failure and uremia have impaired host defenses and wound healing that can lead to an increased risk of infection in addition to a frequent need for surgical procedures with synthetic grafts and catheters. Antibiotic therapy plus timely surgical intervention in removal of infected grafts and catheters is crucial for infection control and patient survival. Other surgical infections, such as wound problems, intraabdominal infections, fungal infections, diabetic foot ulcers, and necrotizing soft tissue infections must be attended to promptly.

Secondary aortoenteric fistula: Contemporary outcome with use of extraanatomic bypass and infected graft excision

The standard treatment for secondary aortoenteric fistula (SAEF) has been infected graft removal (IGR) and extraanatomic bypass (EAB), an approach criticized for its high rate of death, amputation, and disruption of aortic closure. Recently, graft excision and in situ graft replacement has been proposed as a safer treatment alternative. Because the current outcome that can be achieved by use of the standard treatment of SAEF has really not been established, we reviewed the records of 33 patients treated for SAEF at our institution during a contemporary time interval (1980 to 1992). Thirteen patients (39.4%) were admitted with evidence of gastrointestinal bleeding and infection, whereas nine (27.3%) only had bleeding, 10 (30.3%) only had signs of infection, and one SAEF was entirely occult (graft thrombosis). Four patients required emergency operation. The fistula type was anastomotic in 13 (39.4%) patients, paraprosthetic in 15 (45.5%), and not specified in 4 cases. Thirty-two patients underwent EAB followed immediately by IGR (n = 16, 48.5%) or followed by IGR after a short interval, averaging 3.9 days (n = 16, 48.5%). The final patient underwent IGR, followed by EAB. Follow-up on 31 patients (93.9%) averaged 4.4 +/- 3.7 years. There were nine deaths (27.3%) resulting from the SAEF, six perioperative and three late. Three patients (9.1%) had disrupted aortic closure. There were four amputations in three patients (9.1%), two perioperative and two late. Late EAB infection occurred in five patients (15.2%), leading to one death and one amputation. EAB failure occurred in six patients, two during operation and four late, leading to one amputation. The cumulative cure rate for this SAEF group was 70% at 3 years and thereafter. Compared with our earlier SAEF experience, this is a decline of 21% in the mortality rate, 19% in aortic disruption, and 27% in limb loss. We conclude that outcome reports based on SAEF series extending over long time intervals do not accurately represent the results that are currently achieved with standard SAEF treatment with use of EAB plus IGR. This improved outcome is attributed to wide debridement of infected tissue beds, reduced intervals of lower body ischemia, and advances in perioperative management. To determine whether any new treatment approach actually offers improved outcome in the management of SAEF, comparison with EAB plus IGR should be limited to patients treated within the last decade at most.

Improved management of aortic graft infection: the influence of operation sequence and staging.

To investigate the influence of operation sequence and staging on the outcome of aortic graft infection, we studied the mortality and amputation rates and incidence of new graft infection involving the extra-anatomic bypass (EAB) among 101 patients treated for secondary aortoenteric fistula (N = 43) or primary perigraft infection (N = 58). Patients were retrospectively grouped according to the operative treatment technique. Seven patients underwent infected graft removal (IGR) followed immediately by EAB (traditional). Fifty-seven patients were revascularized first, followed by immediate IGR in 38 patients (sequential) or by delayed IGR in 19 patients (staged). The median interoperative interval for the staged group was 5 days (range 2 to 31 days). Twenty patients underwent simultaneous IGR and in-line autogenous reconstruction (synchronous) and finally in 15 patients treatment consisted of IGR only with no extremity revascularization (none). The mean follow-up interval for all patients was 36.8 months. There was no statistically significant difference in mortality rate (traditional, 43%; sequential, 24%; and staged, 26%) or incidence of new graft infection (traditional, 43%; sequential, 18%; or staged, 16%) among those patients treated with EAB, although there was a trend toward an improved outcome with either sequential or staged treatment. There was a significantly lower amputation rate among sequential patients (11%) (p = 0.038) but not staged patients (16%) (p = 0.171) when compared with traditional treatment (43%). Staged operative treatment was associated with significantly less physiologic stress than sequential treatment as reflected by multiple perioperative metabolic variables (95% confidence limits). The treatment groups were comparable in the incidence of aortoenteric fistulas, culture-negative infections, emergent procedures, and appropriate antibiotic use. We conclude that reversed sequence or staged operative treatment of infected aortic grafts can be performed with no increased patient risk. Although traditional or sequential treatment may be required in the setting of acute hemorrhage, the staged operative approach is recommended for the treatment of chronic aortic graft infections.

Improved management of aortic graft infection: The influence of operation sequence and staging

To investigate the influence of operation sequence and staging on the outcome of aortic graft infection, we studied the mortality and amputation rates and incidence of new graft infection involving the extra-anatomic bypass (EAB) among 101 patients treated for secondary aortoenteric fistula (N = 43) or primary perigraft infection (N = 58). Patients were retrospectively grouped according to the operative treatment technique. Seven patients underwent infected graft removal (IGR) followed immediately by EAB (traditional). Fifty-seven patients were revascularized first, followed by immediate IGR in 38 patients (sequential) or by delayed IGR in 19 patients (staged). The median interoperative interval for the staged group was 5 days (range 2 to 31 days). Twenty patients underwent simultaneous IGR and in-line autogenous reconstruction (synchronous) and finally in 15 patients treatment consisted of IGR only with no extremity revascularization (none). The mean follow-up interval for all patients was 36.8 months. There was no statistically significant difference in mortality rate (traditional, 43%; sequential, 24%; and staged, 26%) or incidence of new graft infection (traditional, 43%; sequential, 18%; or staged, 16%) among those patients treated with EAB, although there was a trend toward an improved outcome with either sequential or staged treatment. There was a significantly lower amputation rate among sequential patients (11%) (p = 0.038) but not staged patients (16%) (p = 0.171) when compared with traditional treatment (43%). Staged operative treatment was associated with significantly less physiologic stress than sequential treatment as reflected by multiple perioperative metabolic variables (95% confidence limits). The treatment groups were comparable in the incidence of aortoenteric fistulas, culture-negative infections, emergent procedures, and appropriate antibiotic use. We conclude that reversed sequence or staged operative treatment of infected aortic grafts can be performed with no increased patient risk. Although traditional or sequential treatment may be required in the setting of acute hemorrhage, the staged operative approach is recommended for the treatment of chronic aortic graft infections.