Deep Femoral Vein Reconstruction for Abdominal Aortic Graft Infections is Associated with Low Aneurysm Related Mortality and a High Rate of Permanent Discontinuation of Antimicrobial Treatment

Abstract

WHAT THIS PAPER ADDSThis paper describes the experience of in situ reconstruction of aortic graft and endograft infections using autologous deep femoral vein and reports overall favourable patient outcomes from the procedure. In particular, the explantation of infected aortic endografts was not associated with increased mortality and morbidity, and freedom for antibiotic therapy after one year was high, indicating a high curative treatment rate. Post-operative renal damage was limited, even in patients in need of suprarenal clamping and permanent renal vein division. Autologous vein graft reconstruction of aortic graft and endograft infections represents a method of choice in these challenging patients.Objective: Aortic prosthesis infection is a devastating complication of aortic surgery. In situ reconstruction with the neo-aorto-iliac system (NAIS) bypass technique has become increasingly used and is recommended in recent treatment guidelines. The main aim was to evaluate NAIS procedural outcomes when undertaken after previous open or endovascular aortic repair in Sweden. Methods: In this retrospective study, The National Quality Registry for Vascular Surgery (Swedvasc) was used to identify Swedish centres that offered the NAIS bypass procedure for aortic prosthesis infection between 2008 and 2018. Variables of special interest were procedural details, short and long term survival, renal and other complications, and the durtion of antimicrobial treatment. Results: Forty patients (36 males, four females [mean age 69 years], 32 open repairs, seven endovascular aortic repairs [EVAR] and one fenestrated EVAR; 21 presented with aorto-enteric fistula) operated on with NAIS bypass were reviewed. The median time from the primary aortic intervention to the NAIS bypass procedure was 32 months (range 0 e 252 months). Mean AE standard deviation operating time was 645 AE 160 minutes, mean blood loss was 6 277 AE 6 525 mL, mean length of intensive care unit stay was 5.3 AE 3.7 days, and mean length of overall hospital stay was 21.2 AE 11.4 days. Thirty-five patients (88%) had a positive microbial culture; the most commonly isolated pathogen was Candida spp. The majority of patients survived for 30 days (n ¼ 35 [88%]), and 33 (83%) and 32 (80%) patients survived for 90 days and one year, respectively. The number of surviving patients free from antimicrobial treatment at 90 days, six months, and one year was 19 (58%), 29 (88%), and 30 (94%). After a mean long term follow up of 69.9 AE 44.7 months, 20 patients were still alive. Conclusion:The NAIS bypass procedure offered reasonable survival and functional outcomes, and was associated with a high cure rate, defined as freedom from any antimicrobial treatment.

Clinical outcomes of in situ graft reconstruction in treating infected abdominal aortic stent grafts following endovascular aortic aneurysm repair: a single-center experience

“…Most importantly, it is a very complex and time-consuming procedure. According to a recent study, the mean operating time for this surgery was 645 minutes, which was much longer than the time reported in this present study (433 minutes) [ 28 ]. In our study, banked allograft was used only in the case with intraabdominal sepsis because of limited availability.…”

“…Some authors reported that reconstruction with an allograft or autologous femoral vein has the advantage of reduced rates of infection. However, aortic reconstruction with an allograft must be performed only at a hospital with a tissue bank, and where commercial products have limited availability and/or costlier [ 27 28 29 ]. Additionally, reconstruction with an autologous femoral vein has some disadvantages.…”

Successful surgery for secondary aortoduodenal fistula based on 18F-fluorodeoxyglucose positron emission tomography/computed tomography findings

“…Extra-anatomic bypass with aortic ligation is another strategy. However, it includes the risk of aortic stump rupture 12 and the disadvantage of requiring long-term anticoagulation therapy. Therefore, we performed an aorto-uni type revascularization using a bovine pericardial roll and FF bypass.…”

Treatment of Secondary Aortoenteric Fistulas Following AORTIC Aneurysm Repair in a Tertiary Reference Center

“…Despite a number of proposed therapeutic approaches, a clear therapeutic plan is yet to be defined. There are various techniques described in the literature, including in situ reconstruction with prosthetic materials or deep femoral vein reconstruction with the neo-aorto-iliac system (NAIS), while other authors propose graft excision and extra-anatomic bypass [ 7 , 12 , 13 ]. The significantly worse outcome of patients presenting in hemorrhagic shock and the development of endovascular techniques in the last several years raises the question of whether stent-graft implantation can effectively minimize the perioperative risk in patients presenting with acute life-threatening bleeding [ 14 ].…”