In situ reconstruction for aortic graft infection with autologous FV presents acceptable rates of morbidity and mortality, and remains the treatment of choice for AGI at Helsinki University Hospital.

BackgroundThe treatment of mycotic abdominal aortic aneurysm requires surgery and antimicrobial therapy. Since prosthetic reconstructions carry a considerable risk of reinfection, biological grafts are noteworthy alternatives. The current study evaluated the durability, infection resistance, and midterm outcome of biological grafts in treatment of mycotic abdominal aortic aneurysm.Methods and ResultsAll patients treated with biological graft in 6 countries between 2006 and 2016 were included. Primary outcome measures were 30‐ and 90‐day survival, treatment‐related mortality, and reinfection rate. Secondary outcome measures were overall mortality and graft patency. Fifty‐six patients (46 males) with median age of 69 years (range 35–85) were included. Sixteen patients were immunocompromised (29%), 24 (43%) had concomitant infection, and 12 (21%) presented with rupture. Bacterial culture was isolated from 43 (77%). In‐situ aortic reconstruction was performed using autologous femoral veins in 30 patients (54%), xenopericardial tube‐grafts in 12 (21%), cryopreserved arterial/venous allografts in 9 (16%), and fresh arterial allografts in 5 (9%) patients. During a median follow‐up of 26 months (range 3 weeks–172 months) there were no reinfections and only 3 patients (5%) required assistance with graft patency. Thirty‐day survival was 95% (n=53) and 90‐day survival was 91% (n=51). Treatment‐related mortality was 9% (n=5). Kaplan–Meier estimation of survival at 1 year was 83% (95% confidence interval, 73%–94%) and at 5 years was 71% (52%–89%).ConclusionsMycotic abdominal aortic aneurysm repair with biological grafts is a durable option for patients fit for surgery presenting an excellent infection resistance and good overall survival.

Objective The objective of this systematic literature review was to explore the value of positron emission tomography combined with low-dose computed tomography (18F-FDG-PET-CT) in the diagnostics of infective native aortic aneurysm (INAA). Methods A systematic literature review was performed using the search terms mycotic- and infected aortic aneurysms in Medline and Sciencedirect databases, published between 1 January 2000 and 1 January 2020. Using the PRISMA statement, articles were scrutinized according to a predefined protocol including: timing of 18F-FDG-PET-CT examination, the maximum standardized uptake value (SUVmax), additional findings on examination, and findings on repeated scanning of 18F-FDG-PET-CT. Results Four studies were included in the analysis, comprising a total of 11 patients. Two studies were single case reports, and two were small case series, all were graded to be of low quality with high risk of bias. All patients were examined with a preoperative 18F-FDG-PET-CT, and 10 (91%) had increased 18F-FDG uptakes. The median SUVmax value was 6.53, range 4.46–9.23. The mean duration of antibiotic therapy prior to 18F-FDG-PET-CT was not known. Two patients were examined with repeated 18F-FDG-PET-CT examinations after treatment, where a decrease in SUVmax values could be demonstrated after successful treatment. Conclusion The literature on 18F-FDF-PET/CT for diagnosing infective native aortic aneurysms is scarce. However, there might be a role for 18F-FDF-PET/CT in the management of the disease, in particular for patients with clinical suspicion of INAA without convincing findings on CT. SUVmax values ranging from 4.5 to 6.5 could be guiding and suggestive of metabolic activity in agreement of INAA. However, further conclusions on its usefulness, robustness and specific SUVmax values are premature, and a definitive cut-off value is probably not attainable.

WHAT THIS PAPER ADDS The current study introduces arterial reconstructions with cryopreserved femoral and vena caval vein allografts as a novel technique in the supra-inguinal setting with a low rate of re-infections and acceptable number of graft re-interventions on mid term analysis. Objective: This study introduces a novel technique for supra-inguinal arterial reconstructions with cryopreserved femoral vein and caval allografts with a low re-infection rate and an acceptable graft re-intervention rate on early mid term analysis. Methods: Patients treated from February 2012 to March 2018 with cryopreserved venous allograft reconstructions owing to infection in the supra-inguinal area were reviewed retrospectively. The primary end points were re-infection and the treatment related mortality rate. Secondary end points were 30 and 90 day and overall mortality and graft re-intervention rate. Results: Of the 23 patients treated with cryopreserved venous allografts for infection in aorto-iliac area, 21 (91%) patients underwent reconstruction with cryopreserved femoral veins and two (9%) with vena cava. Indications for treatment were aortic graft infections (n ¼ 12 [52%]), mycotic aneurysms (n ¼ 5 [22%]), femorofemoral prosthetic infections (n ¼ 3 [13%]), anastomotic pseudo-aneurysms (n ¼ 2 [9%]), and aortic thrombosis with intestinal spillage (n ¼ 1 [4%]). In hospital and 90 day mortality were 9% (n ¼ 2); overall treatment related mortality during the median follow up of 15 months was 13% (n ¼ 3). During the follow up, two allografts were re-operated on owing to anastomotic dilatation and one because of re-infection, resulting in a reintervention rate of 13% (n ¼ 3). None of the grafts was lost and there were no amputations. At the end of follow up 17 patients (74%) were alive. KaplaneMeier estimation for survival was 76% (95% confidence interval [CI] 57%e95%) at one year and 70% (95% CI 49%e91%) at two years. Conclusion: Cryopreserved venous allografts appear to be an infection resistant and reasonably safe reconstruction material in the aorto-iliac axis based upon the early mid term analysis from a single centre experience. Further research is needed to compare their performance with other biological reconstruction material.

Objectives: Genetic background has been identified to be a major predictor of post-clopidogrel platelet inhibition in patients undergoing coronary stenting. However, there is a lack of data on clopidogrel response regarding genotype in patients undergoing carotid artery stenting (CAS). The influence of the most common allelic variants of CYP2C19 phenotypes and genotypes on response to baseline clopidogrel and on the pharmacodynamic effect of dose adjustment (high or standard dose of clopidogrel) in patients with high on-treatment reactivity after CAS was investigated.Methods: Platelet reactivity was assessed before and 30 days after carotid stenting using the VerifyNow P2Y12 assay to obtain P2Y12 reactivity unit (PRU) values.Results: A total of 209 patients (79.4% male, 44.1% currents smokers) were treated by CAS. Smokers improved responsiveness to clopidogrel (P ¼ .034). With respect to CYP2C19 enzymatic function, 61 subjects (29.1%) were ultra-rapid metabolizers, 95 patients (45.5%) were extensive metabolizers, 51 (24.4%) were intermediate metabolizers, and two (0.96%) were poor metabolizers. Baseline PRU was significantly higher among intermediatedpoor metabolizers compared with ultra-rapid (P ¼ .001) or extensive metabolizers (P ¼ .005). At 30 days follow up, in non-responding patients with the intermediatedpoor metabolizer phenotype, the PRU value and inhibition percentage were significantly reduced with standard dose (P ¼ .008; P ¼ .0029) and high dose of clopidogrel (P ¼ .00 0; P ¼ .000). However, high dose clopidogrel did not achieve a more intense pharmacodynamic effect at 30 days (P ¼ .994) compared with standard dose.Conclusions: In patients undergoing carotid stenting, those with the CYP2C19*2 allele had increased basal PRU values and in fact clopidogrel non-responders increased significantly among intermediatedpoor metabolizers. Although high dose and standard dose clopidogrel therapy was effective in lowering the 30 day PRU values in patients with high on-treatment reactivity who are intermediatedpoor metabolizers, the use of high dose clopidogrel did not result in statistically significantly greater reductions in reactivity compared with the standard dose. Aortic Curvature Instead of Angulation Allows Improved Estimation of the True Aorto-iliac Trajectory Schuurmann R.C.L., Kuster L., Slump C.H., Vahl A., van den Heuvel D.A.F., Ouriel K., de Vries J.-P.P.M. Eur J Vasc Endovasc Surg 2016;51:216-24.Objective: Supra-and infrarenal aortic neck angulation have been associated with complications after endovascular aortic aneurysm repair. However, a uniform angulation measurement method is lacking and the concept of angulation suggests a triangular oversimplification of the aortic anatomy. (Semi-)automated calculation of curvature along the center luminal line describes the actual trajectory of the aorta. This study proposes a methodology for calculating aortic (neck) curvature and suggests an additional method based on available tools in current workstations: curvature by digital calipers (CDC).Methods: ...

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Purpose of reviewInfective native aortic aneurysms (INAAs) are challenging and complex with both bacteraemia and an aneurysm prone to rupture. They are fatal unless recognized and treated promptly. The rarity of the disease makes it unfamiliar to most physicians, which might delay both diagnosis and treatment. The present review aims to outline the recently published diagnostic algorithm of INAAs, the main characteristics of the disease and present an overview of contemporary treatment strategies. Recent findingsNew terminology, definition, diagnostic algorithm and reporting standards have recently been proposed for INAAs. Current evidence concerning the treatment of INAAs is founded on retrospective register-based multicentre studies and small single-centre studies. Recent findings encourage the use of endovascular aortic repair (EVAR) for surgical treatment of INAAs. Although EVAR, as a surgical approach, does not drain the infection, the postoperative infection-related complication rates (IRCs) are similar to the ones reported after open surgical repair (OSR) with aortic prosthetic reconstruction and extensive debridement. IRCs carry over 50% risk of being fatal. Postoperative mortality after EVAR remains considerably lower supporting the use of method for aged and comorbid group of patients. Biological grafts have the benefit of being more resistant to reinfection. OSR with biological reconstruction is a promising surgical approach for patients fit for open surgery; however, data are scarce and long-term follow-up is lacking.

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