Total excision and extra-anatomic bypass for aortic graft infection

Ricotta, John J.; Faggioli, Gianluca; Stella, Andréa; Curl, G. Richard; Peer, Richard M.; Upson, James F.; D'Addato, M; Anain, Joseph M.; Gutierrez, Irineo Z.

doi:10.1016/0002-9610(91)90177-f

Cited by 101 publications

(47 citation statements)

References 23 publications

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“…This compared with a previous report from the same institution, although Staphylococcus epidermidis was not cultured from the graft in the previous report. 1 The predominance of gram-positive organisms in our study is in agreement with others 15 and this raises the possibility of skin-originating contamination. Therefore, the use of an antibiotic that would cover both gram-positive and gram-negative organisms is advisable prior to culture results.…”

Section: Discussionsupporting

confidence: 92%

Infected Abdominal Aortic Grafts

Alshehri¹,

McPhail²,

Barber³

et al. 1994

Annals of Saudi Medicine

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Aortic grafts were inserted in 1711 patients at Ottawa Civic Hospital (OCH) between 1976 and 1986. Aorto-iliac occlusive disease was the indication in 884 while in 827, the graft was inserted for abdominal aortic aneurysms. Graft infection occurred in 12 patients; six presenting with gastrointestinal bleeding due to aorto-enteric fistula (AEF) and the other six presenting with groin abscesses, mostly as a draining sinus. These were treated with graft excision and immediate extra-anatomic bypass. Seven patients died, giving a mortality rate of 58%. Three surviving patients required above-knee amputation. These results are comparable to the results of others in the literature; therefore, continuing assessment of all aspects of graft infection and the search for more effective methods of prevention and management are needed.

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Section: Discussionsupporting

confidence: 92%

Infected Abdominal Aortic Grafts

Alshehri¹,

McPhail²,

Barber³

et al. 1994

Annals of Saudi Medicine

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“…This procedure, first performed in the 1960s, was accepted as the standard of care against which other procedures were measured. 5,83,[92][93][94][95][96][97][98][99] In selected patients, it is still considered to be the treatment of choice. However, the major disadvantages of extra-anatomic bypass followed by graft excision are lower short-and long-term patency rates of the bypass graft; a 2-stage, lengthy surgical procedure; relatively high rate of amputation of the lower extremity; risk of rupture of the stump at the aortic suture line, with potentially life-threatening hemorrhage; and difficulty establishing an extra-anatomic revascularization route in the inguinal region.…”

Section: Intra-abdominalmentioning

confidence: 99%

“…8,11,27 In the past, the "gold standard" management of these patients was extra-anatomic bypass surgery followed by graft excision. 5,83,[92][93][94][95][96][97][98][99]111 In selected patients, that might still be the procedure of choice; however, because of the high rates of mortality and potential complications, including limb loss, numerous studies have suggested that alternative surgical options might be preferable to extra-anatomic bypass and graft excision. For patients with aortoenteric fistula caused by methicillin-sensitive S aureus or less virulent microorganisms, such as coagulase-negative staphylococci, streptococci, susceptible enterococci, or susceptible enteric gram-negative bacilli, graft excision and in situ reconstruction with either cryopreserved or fresh arterial allograft, venous autograft, or rifampin-bonded synthetic graft are reasonable.…”

Section: Graft Excision and In Situ Reconstructionmentioning

confidence: 99%

“…4,[92][93][94][95][96][97][98][99]111 The primary reason for this recommendation is because of the risk of recurrent infection that can occur with in situ reconstruction. 4,[92][93][94][95][96][97][98][99]111 The major disadvantages of extra-anatomic bypass grafting and graft excision are as follows: (1) a 2-stage procedure is required; (2) conduit failure with amputation of lower extremities has been observed in 20% to 30% of patients; (3) blood supply is decreased with ischemia to the inferior mesenteric and internal iliac arteries; and (4) residual infection of the aortic stump with blowout occurs in 10% to 20% of patients. 4 Theoretically, the risk of recurrent infection should be lower with this procedure, because the VGI is resected with no in situ reconstruction in an infected tissue bed; however, in the meta-analysis published by O'Connor et al, 4 the infection rate was highest with this procedure, followed by rifampin-bonded, then arterial allograft, and lowest with venous autograft.…”

Section: Extensive Intra-abdominal Abscess or Gross Purulence Around mentioning

confidence: 99%

See 1 more Smart Citation

Vascular Graft Infections, Mycotic Aneurysms, and Endovascular Infections: A Scientific Statement From the American Heart Association

Wilson¹,

Bower²,

Creager³

et al. 2016

Circulation

333

278

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The use of synthetic material for reconstructive vascular surgery was first reported during the early 1950s. Infection involving vascular graft prostheses is an infrequent but devastating complication of reconstructive vascular graft surgery and is associated with a high morbidity and, in some situations, mortality. Improvements in surgical techniques and graft design, including the use of native venous or arterial tissue, have reduced the frequency of infection and severity of complications from vascular graft infection (VGI). However, these advances have also led to more frequent vascular graft procedures occurring in a patient population with multiple underlying comorbidities that would have previously disqualified them as candidates for vascular reconstructive surgery. Underlying comorbidities, such as diabetes mellitus or immune compromise, increase the risk of infection and serious infection-related complications. The major complications of VGI include sepsis, amputation, disruption of infected anastomotic suture line with rupture or pseudoaneurysm formation, embolization of infected thrombi, reinfection of reconstructed vascular grafts, enteric fistulae to the small or large bowel, bacteremic spread of infection to other sites, and death. VGIs can be categorized broadly into those that occur in an extracavitary location, primarily in the groin or lower extremities, or in an intracavitary location, primarily within the abdomen or less commonly within the thorax. frequencyThe frequency of VGI depends on the anatomic location of the graft. The infection rate is 1.5% to 2% for most extracavitary grafts and as high as 6% with vascular grafts in the groin. [1][2][3][4][5][6][7][8][9] For intracavitary grafts, the infection rate is ≈1% to 5%. 1-6 Graft infection is most common after emergency procedures and after reoperation. [1][2][3][4]10 Aortic graft erosion or fistulous communication into the duodenum or other areas of the bowel reportedly occurs in 1% to 2% of patients after aortic reconstruction. 11,12 MicrobiologyThe microbiological cause of VGI has evolved over the years. 1 In early published studies, Staphylococcus aureus was the predominant microorganism recovered. 1,13 Improvements in surgical technique, administration of prophylactic antistaphylococcal antimicrobial therapy, and other factors have resulted in a changing microbiological epidemiology. Vascular graft surgery performed on patients with multiple underlying comorbidities and the increased frequency of emergency procedures have contributed to the changing spectrum of infection. Other factors such as changes in hospital flora, surgery in patients with complicated vascular anatomy, and multiple revisions of previous vascular surgery have resulted in a more diverse microbio- clInIcal stateMents anD GuIDelInes logical spectrum of infection, which includes multidrugresistant strains, polymicrobial infection, and Candida species. Gram-positive cocci accounts for at least two thirds of VGIs. 1,13 Infections caused by coagulase-negative staphylococ...

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“…Also, one of our patients died as a result of the dysfunction of the aortic stump, which was primarily covered by the omental flap. A rare, but equally important inconvenience is the regression of circulation in the pelvic organs and of lower extremity haemodynamics, or the possibility of thrombus formation in the aortic stump, which may close the lumina of the renal arteries [8]. Another potential complication is the spread of the infection beyond the initial area, which may lead to the development of false aneurysms and, for example, involve axillary arteries [7,9], which we observed in one of our patients.…”

Section: Discussionmentioning

confidence: 83%