Treatment Of Aortic Graft Infection Research Articles

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.

Comparison of different surgical approaches for treating aortic graft infections.

There is still no guideline or consensus on the treatment of aortic graft infection. This study reported and compared conservative and surgical treatment and different surgical methods for aortic graft infection. Data from aortic graft infections treated at our institution between February 2017 and June 2022 were retrospectively analyzed. Clinical data and surgical approaches were evaluated. This article retrospectively analyzed the treatment and prognosis of 48 patients (43 males) with aortic graft infection. The patients were divided into conservative treatment group (n = 15) and surgical treatment group (n = 33). During follow-up, the mortality rate of the conservative treatment group was significantly higher than that of the surgical treatment group (P<0.05). The survival curve also showed that the survival time of the surgical treatment group was longer than that of the conservative treatment group (P<0.05). The surgical treatment group included local treatment (n=5), in situ replacement (n=8) and bypass surgery (n=20) groups. There was no significant difference in the mortality rate at 1 month or final follow-up among the local treatment, in situ replacement and bypass surgery groups. Surgical treatment is the optimal option for treating aortic graft infections compared to conservative treatment.

A case series of image-guided percutaneous drainage of abdominal aortic graft infection as bridge therapy.

Aortic graft infection (AGI) is a rare complication following endovascular aneurysm repair and is associated with substantial morbidity and mortality. The traditional management of AGI is intravenous antibiotic therapy and surgical explantation. In this case series, percutaneous drainage was used as a bridge therapy in the treatment of AGI. We report two cases, 78-year-old male and 57-year-old female, in whom image-guided percutaneous drainage was used to treat AGI in two contrasting contexts. Informed consent was obtained from both cases/relatives for publication. Both cases underwent successful percutaneous drainage of AGI utilized as a bridge therapy before definitive surgical reconstruction and graft explantation. Each patient had a different outcome. In the first case, the patient's comorbidities and severe disease state could not be overcome, resulting in his death. The second patient benefitted from the percutaneous drainage by allowing her more time ameliorate her malnutrition before definitive surgery. Data on the outcomes of percutaneous drainage of AGI is limited. The successful procedure described in this case series emphasizes the need to conduct more research to evaluate the safety and efficacy of this treatment approach before the surgical explantation.

Neoaortoiliac system and cryopreserved human allograft for the treatment of aortic graft infections.

To report and compare neoaortoiliac system reconstruction and cryopreserved human allograft in treating aortic graft infections. We retrospectively analysed the data of the patients treated for aorto graft infections between January 2015 and May 2021 in our hospital. The clinical data, diagnostic procedures, and surgical options were evaluated. The primary endpoint of this study was the 30-day and 1-year mortality; secondary endpoints were major postoperative complications. We retrospectively reviewed a series of 31 consecutive patients (28 males; median age 72years, range, 50-87years) with aortic graft infection treated with NAIS (n = 20, 65%) or cryopreserved allograft (n = 11, 36%). The clinical presentation included fever attacks in 18 (58%) patients, abdominal pain in 15 (48%) patients, haemodynamic instability in 6 (19%) patients, and haematemesis in 2 (7%) patients. The median operative time of the NAIS was longer than CHA without a statistically significant difference (458 min vs. 359 min, p = .505). The postoperative morbidity for all patients was 81%, with no significant difference between NAIS and CHA groups (85% vs. 73%, p = .638). There was no limb thrombosis of the new reconstructions. Limb loss occurred in 4 (13%) patients, including 2 (10%) NAIS patients and 2 (18%) CHA patients. One NAIS patient developed complications in the form of a distal (femoral) disruption of the vein 15days after surgery. There were no significant differences between NAIS and CHA groups in ICU stay (12 vs 8days, .984) but in hospitalization (22 vs 33, p = .033). The most common bacteria isolated were staphylococci strains in 15 (48%). In 13 (36%) patients, candida was positive. The in-hospital 30-day and 1-year mortality for all patients was 16% (5/31) and 29% (9/31), with no significant differences between NAIS and CHA at 30days (25% vs. 0, p = .133) or 1year (35% vs. 18%, .429). Five NAIS patients died during the hospital stay; three of them had end-of-life decisions. After a median follow-up of 16months (1-66months), 12 (39%) patients died, including 9 patients with NAIS and 3 with CHA reconstructions. The causes of death included overwhelming sepsis in 5 (42%) patients, graft disruption in one (8%) NAIS patient, non-small cell lung cancer in one (8%) patient, COVID-19 in one (8%) patient and unknown causes (8%) in one. Non-staged neoaortoiliac system reconstruction and cryopreserved human allografts show comparable short- and midterm results for treating aortic graft infections. However, both procedures remain challenging with high morbidity and mortality rates.

Neoaortoiliac system in treating aortic graft infections: a single center long-term experience and review of the literature.

Aortic graft infection represents one of the most challenging and life-threatening complication of surgical and endovascular treatment of aortic pathologies. The aim of this study was to report the results of a single center with in-situ revascularization for the treatment of aortic graft infections using the neo-aorto-iliac system (NAIS) and to review the literature about this surgical technique. We retrospectively reviewed our aortic graft infection case series and in-situ revascularization using the neo-aorto-iliac system. The study was conducted from January 2009 to June 2020. The primary outcomes analyzed were early mortality (<30 days), late mortality (>30 days), reinfection rate. Secondary outcomes were the primary patency rate, the secondary patency rate, and the lower limb salvage rate. A literature review of the last twenty years was performed on international medical databases Pubmed (Medline), Scopus and Web of Science. During study period, 12 patients, all male (median age of 69 years [range: 52-87 years]), underwent to infected graft explantation and revascularization by NAIS using femoral-popliteal veins. Six cases were complicated by aorto-enteric fistulas, five were duodenal and one was colon. Patients spent the immediate postoperative period in the Intensive Care Unit for a median time of 4 days (range: 0-9 days). The median length of hospital stay was 27.5 days (range: 1-66 days). The mean follow-up was 21.5 months (range: 0-120). The 30-day mortality rate was 25% (3 patients) due to postoperative complications. No patient dropped out of the follow-up protocol. The primary patency rate was 92% while the secondary patency rate was 100%. No patient underwent lower limb amputation. Persistence of infection occurred in 1 case (8.3%). Overall Kaplan-Meier survival estimates were 75% for 30 days, 50% for 1 year, 48% for 5 years. Literature analysis identified 19 case series. The literature regarding NAIS has low statistical evidence due to retrospective design of the studies. Our results are in agreement with retrospective studies in the literature. When the surgical team is confident with NAIS, this technique should be considered the preferred method, considering an acceptable and comparable mortality rate with other techniques and a better rate of patency, resistance to graft degeneration, recurrent infections and amputation rate.

A 73-year-old woman with delayed intra-abdominal and systemic sepsis following complicated aortobifemoral bypass

A 73-year-old woman with delayed intra-abdominal and systemic sepsis following complicated aortobifemoral bypass

SURGICAL MANAGEMENT AND BACTERIOLOGICAL OUTCOME OF INFRARENAL ABDOMINAL AORTIC GRAFT INFECTION AT A SINGLE CENTRE

Aim: Primary outcome measures was to analyze the clinical consequence of patients who treated for infrarenal aorta synthetic graft infection ( SGI) with extra-anatomical bypass (axillobifemoral (AXF)) or in situ reconstruction (ISR). Secondary outcome measure was to show bacteriological analysis of abdominal aorta graft infection. Method: Analysis of medical records of 24 patients treated for SGI at Jordanian Royal Medical Services between June 2010 and Aug 2020 were retrospectively reviewed. For all patients, we recorded clinical features , morbidity and mortality , as well as bacteriology results, and antibiotic treatment . Result: We identified 24(3%) patients with SGI .The median follow up duration was 22 months range (8-84months). The median age was 52 years and 18 were males. An in situ prosthetic graft replacement, using rifampin-soaked polyester graft was performed in 10 patients(42%) and AXF in 14 patients((58%). The early hospital mortality rate was 4 (17 %.) owing to bowel ischemia 1 patient, 2 patients with septicemia and one patient with aortic stump blowout . There were no late procedure-related deaths during follow up period Primary patency and limb salvage rates at 3 years were 80 %(2 patients ) for ISR and 90%( 2 patients) for AXF. The incidence of graft reinfection was 10% (1 patient) for ISR and 8 %(2 patients) for AXF. Graft reinfection occurred in 3 patients (12.5%) was not associated with procedure-related death .Microbiology specimens obtained from the graft and the tissues were positive in 21 patients(88%). Poly microbial Gram-positive organisms were the most dominant bacteria found in 10 patients (42%). The mean length of hospital stay was 17 days . Conclusion: According to our study ISR and AXF is a safe and effective in treatment of aortic graft infection. Graft reinfection occurred in 12.5% of the patients. The graft patency and limb salvages rates were considered satisfactory.

Treatment of Aortic Graft Infection with in Situ Replacement with a Superficial Femoral Vein Graft

Treatment of Aortic Graft Infection with in Situ Replacement with a Superficial Femoral Vein Graft

Systematic Review and Meta: Analysis of Aortic Graft Infections following Abdominal Aortic Aneurysm Repair.

Introduction. Aortic graft infection (AGI) is a rare complication following AAA repair and is associated with high morbidity and mortality. Management is variable, and there are no evidence-based guidelines. The aim of this study was to systematically review and analyse management options for AGI. Methods Data was collected between July and August 2018. A full HDAS search was conducted on the following databases: MEDLINE, EMBASE, CINAHL, and PUBMED. Meta-analysis was conducted using RevMan 5 software. Results 1,365 patient outcomes were assessed (10 cohort studies and 12 comparative studies). The most common treatment was in situ replacement of the graft (ISR) followed by extra-anatomical replacement (EAR). Various grafts were used for ISR, such as fresh/cryopreserved allograft, venous graft, and prosthetic grafts. No graft material was shown to be superior. Axillobifemoral graft was the commonest type of EAR used. In the majority of cohort studies, ISR was the main treatment for AGI. There was no significant difference in the overall mortality rate (ISR n = 70/176 vs. EAR n = 70/176 vs. EAR P = 0.87). Graft occlusion rate was significantly lower in the ISR group vs. the EAR group (n = 70/176 vs. EAR n = 70/176 vs. EAR P = 0.87). Graft occlusion rate was significantly lower in the ISR group vs. the EAR group (n = 70/176 vs. EAR n = 70/176 vs. EAR P = 0.87). Graft occlusion rate was significantly lower in the ISR group vs. the EAR group (Discussion. In situ replacement is the preferred method of treatment as it had lower rates of occlusion. Further strong evidence is required, such as a multicentre trial to establish a management pathway for the condition.

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.

Current status of treatment for aortic graft infection: When should cryopreserved allografts be used?

Aortic graft infection remains one of the most complex clinical challenges faced by vascular specialists, and is often associated with significant patient morbidity and mortality regardless of the approach used for management. The cryopreserved aortic allograft is now a commonly used in situ aortic replacement in the management of graft infection, and is preferred over rifampin-soaked prosthetic grafts. In the review, we summarize the indications for cryopreserved aortic allograft usage, as well as operative technique, clinical results, and alternative treatments. We propose the use of a novel term tertiary aortic fistula, to distinguish aortic fistulae in the setting of aortic endograft infection, a clinical entity whose natural history and best management are currently being characterized.

Outcomes of Surgical Explantation of Infected Aortic Grafts After Endovascular and Open Abdominal Aneurysm Repair

Infection of the vascular graft represents one of the most threatening complications after aortic repair. It is rare and associated with high morbidity and mortality rates. The aim of this study was to present short-term outcomes after surgical treatment of infected aortic grafts after endovascular and open repair of abdominal aortic aneurysms (AAAs). Data of all patients affected by aortic graft infection after aneurysm repair who underwent an explantation of a conventional or endovascular aortic graft between January 2008 and December 2016 were retrospectively reviewed. All patients underwent in situ reconstruction using a rifampicin soaked synthetic graft. The primary endpoint of this study was 30 day mortality; secondary endpoints were major post-operative complications. Twenty-six patients were included in the cohort, 16 with an infected endograft (iEVAR) and 10 patients with an infected conventional graft (iOAR). Thirty-day mortality was 23.1% overall, 37.5% for iEVAR and 0% (p=.027) for iOAR. Post-operative major complications occurred in eight (50%) patients from the iEVAR group and in four (40%) patients from the iOAR group (p=.619). The supravisceral clamping rate was higher in patients with infected iEVAR (93.8 vs. 20%, p=.001), furthermore a greater incidence of post-operative acute kidney injury was observed (50 vs. 0%, p=.009). Explantation of the graft and in situ reconstruction for aortic graft infection is accepted as the therapy of choice. However, re-operation for iEVAR is related to significantly higher mortality and morbidity rates. The need for suprarenal aortic clamping seems to be a possible explanation for worse outcomes in iEVAR.

Long-term Successful Antibiotic Therapy for Recurrent Aortic Graft Infection.

ObjectiveTo report a case of successful long-term conservative management of a patient with aortic graft infection due to multiple infectious agents.Materials and methodsWe describe the clinical case and present a review of relevant literature.ResultsAn 82-year-old man presented with recurrent Escherichia coli bacteraemia. He was diagnosed with an endovascular aortic graft infection. As the patient declined surgery, conservative treatment with daily antibiotic therapy was instituted. We report good clinical results after almost 2 years of treatment and follow-up.ConclusionsThe preferred treatment of aortic graft infections is surgical. Conservative management is usually offered to poor surgical candidates and is associated with an unfavourable outcome. However, we report that selected patients may be successfully treated using prolonged antibiotic therapy.LEARNING POINTSEndovascular graft infection is a serious, potentially life-threatening complication of aortic aneurism repair.Surgical management is the preferred therapeutic approach; information about conservative therapy options and their outcomes is limited.Long-term conservative management with ambulatory maintenance antibiotic therapy is an adequate treatment alternative and in selected patients can lead to a good clinical outcome.

Surgical treatment of aortic graft infections

Surgical treatment of aortic graft infections

Treatment of Aortic Graft Infection in the Endovascular Era.

This review provides an overview of the current literature surrounding the medical and surgical treatment of aortic graft infection with particular focus on the role of endovascular aortic grafts in the changing demographics and management of these infections. Definitive therapy for aortic graft infection continues to include parenteral antibiotics and surgical explantation and revascularization procedures, which are historically vast operations and sources of significant operative stress. Surgical management has evolved to include more options for infection resistant in situ conduits, attempts at partial explantations, and use of endovascular therapy to temporize the urgent sequelae of these infections, such as aortoenteric fistula. Aortic graft infection continues to be a significant and morbid complication of graft placement even with the advent of endovascular therapy, and its treatment will only increase in difficulty as a more frail population has gained access to complex aortic repair. In the future, more flexible revascularization and partial explantation options are keys, along with long-term suppressive antibiotics where appropriate.

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.

VS01. Neoaortoiliac System (NAIS) Procedure for Infected Aortobifemoral Graft

The neoaortic system (NAIS) procedure has been previously described for the treatment of infected aortic grafts, but the technical details of execution are elusive to the majority of vascular surgeons. In this video, we demonstrate the key steps involved in performing a successful NAIS. http://www.conferenceabstracts.com/uploads/cfp2/attachments/ZRFDQHCR/ZRFDQHCR-291895-1-ANY.mov

Candidemia with Prosthetic Aortic Graft: Case Report

Infections of prosthetic aortic grafts status post-acute aortic dissection with Candida albicans (C. albicans) are rare. The gold standard of treatment for aortic graft infection is a combination of surgical resection and lifelong antimicrobial drug therapy, however postoperative mortality rates remain high. Here we present a 44-year-old man who presented with 2 months of fever, painful microembolic lesions localized to his right hypothenar eminence, right conjunctival hyperemia, right neural hearing loss, and a systolic murmur radiating from the aorta towards the neck. C. albicans was isolated from 3 separate blood cultures. Computed tomography (CT) displayed distinct thrombotic material affixed to the aortic prosthetic graft in the brachiocephalic artery. The patient was then treated with intravenous (IV) fluconazole for 8 weeks. During the treatment period, the patient suffered from brain hemorrhage in the right temporal lobe, presenting with hemiparalysis. After 8 weeks on IV fluconazole, oral fluconazole was then administered. Through 12 months of follow up, he remained asymptomatic, lab values only notable for slightly elevated inflammatory markers. This case suggests that for some patients, either unwilling or unable to endure surgery, candidemia associated with a prosthetic graft can be managed conservatively, with antifungal therapy alone.

Long-Term Results of the NAIS Procedure for Aortic-Graft Infections and Mycotic Aneurysms: A Single-Center Experience

Introduction: Since the neo-aortoiliac system (NAIS) procedure was first described, the treatment of aortic graft infections and mycotic aneurysms has markedly evolved. Many centers have published their short-term and mid-term results using this procedure but evidence is limited regarding longer follow-up. The goal of this study was to evaluate the long-term outcome of a single center's cohort of patients treated with a NAIS reconstruction for aortic infections and to identify variables associated with a negative outcome. Methods: 75 patients who underwent a NAIS procedure at our institution from January 2000 to December 2015 were identified using our center's database. Demographics, clinical presentation, operative data, post-operative and long-term outcomes were collected. Results: NAIS reconstructions were performed for 56 aortic graft infections (including 21 aorto-enteric fistulas) and 19 aortic mycotic aneurysms. The graft configuration mostly associated with infection was aortobifemoral (71%). Peroperative cultures were positive in 55 patients (73,4%) and 27% were polymicrobial. Thirty-day mortality was 13% and in-hospital mortality was 17%. Significant post-operative complications included 3 major amputations (4%) and 8 anastomotic ruptures from reinfection (11%). Perioperative death predictors included diagnosis at presentation (aortic graft infections vs mycotic aneurysms), positive per-operative cultures, fungal infections and post-operative anastomotic rupture of the NAIS. Primary graft patency at 1 and 5 years were 84% and 63%, and secondary patency rates were 95% and 92% respectively. Limb salvage at 5 years was 95%. First-year survival was 83% and five-year survival was 63%. Conclusion: These results indicate that the NAIS procedure is a reliable option to treat aortic infections with acceptable perioperative complications. Ultimately, most patients demonstrate a favorable long-term outcome after the post-operative period. Indeed, the durability of the procedure is its best feature and is demonstrated by excellent graft patencies, and low amputation and reinfection rates. Disclosure of Interest: None Declared.