Long-Term Survival After Coverage With Prevertebral Fascia for Abdominal Aortic Stump Closure

Abstract

Abdominal aortic graft-enteric fistula is an uncommon but grave complication. Acceptable early results of its management have been reported in recent years, but aortic stump disruption remains a dreaded problem in the remote period. This report describes a case of a 71-year-old male with graft-enteric fistula following after a distant abdominal aortic aneurysm repair. The patient underwent 1-stage operation with extra-anatomic bypass preceding the complete removal of the infected aortic graft and intestinal repair. For coverage of the aortic stump closure, the prevertebral fascia was harvested as a flap and was successfully used to buttress the closure. Additionally, omental wrap was secured around the stump and around the area after complete graft removal. Postoperative intravenous antibiotic with meropenem was administered for 8 weeks, followed by suppression with ongoing oral antibiotic with trimethoprim-sulfamethoxazole for 6 months. Although sigmoidectomy and the left ureteral reconstruction were required, the patient is doing well without recurrent infection and without stump disruption after 8 years of follow-up.

Editor's Choice – European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Vascular Graft and Endograft Infections

“…During ISR, the proximal anastomosis can be re-inforced with fascia. 143,171 After inserting the new VG, it should be covered by biological material, especially pediculed omentum flap, muscle, fascia, or retroperitoneal tissue. 171 An omental wrap around the graft lowers the rate of infection, even when rifampicin or silver coated VGs are used.…”

“…143,171 After inserting the new VG, it should be covered by biological material, especially pediculed omentum flap, muscle, fascia, or retroperitoneal tissue. 171 An omental wrap around the graft lowers the rate of infection, even when rifampicin or silver coated VGs are used. 144,155 There are insufficient data on the efficacy of bio-absorbable and non-absorbable local antibiotic beads or sponges, and reported data have described their use in an extracavity position only.…”

Vascular graft infections

“…Thus, current clinical practice guidelines recommend ISR over EAB [4,5] . In patients with partial or complete removal of infected graft/endograft, it is recommended to cover the new graft with viable tissue [60] . Several biological alternatives exist such as pedicled omentum flap, muscle (intercostal or latissimus), fascia, or retroperitoneal tissue [4] .…”

“…Currently, and as a natural consequence of broader use of TEVAR compared to open repair, infected endografts are more commonly observed and reported [80] . Kahlberg et al [60] studied outcomes for open surgical grafts and endograft infections. Mortality rates at 30 days, 1 year, and 5 years were 33%, 57%, and 82% after open repair, whereas after TEVAR they were 26%, 54%, and 81%, respectively.…”