Aortic prosthetic infection: 50 patients treated by radical or local surgery

Surgical and medical interventions for abdominal aortic graft infections

BACKGROUND

Abdominal aortic graft infections are a major complication following abdominal aortic aneurysm surgery, with high morbidity and mortality rates. They can be treated surgically or conservatively using medical management. The two most common surgical techniques are in situ replacement of the graft and extra-anatomical bypass. Medical management most commonly consists of a course of long-term antibiotics. There is currently no consensus on which intervention (extra-anatomical bypass, in situ replacement, or medical) is the most effective in managing abdominal aortic graft infections. Whilst in emergency or complex situations such as graft rupture surgical management is the only option, in non-emergency situations it is often personal preference that influences the clinician's decision-making.

OBJECTIVES

To assess and compare the effects of surgical and medical interventions for abdominal aortic graft infections.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and WHO ICTRP and ClinicalTrials.gov trials registers to 2 December 2019. We also reviewed the bibliographies of the studies identified by the search and contacted specialists in the field and study authors to request information on any possible unpublished data.

SELECTION CRITERIA

We aimed to include all randomised controlled trials that used surgical or medical interventions to treat abdominal aortic graft infections. The definitions of abdominal aortic graft infections were accepted as presented in the individual studies, and included secondary infection due to aortoenteric fistula. We excluded studies presenting data on prosthetic graft infections in general, unless data specific to abdominal aortic graft infections could be isolated.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all studies identified by the search. We planned to independently assess risk of bias of the included trials and to evaluate the quality of the evidence using the GRADE approach. Our main outcomes were overall mortality, amputation, graft re-infection, overall graft-related complications, graft-related mortality, acute limb ischaemia, and re-intervention.

MAIN RESULTS

We identified no randomised controlled trials to conduct meta-analysis.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence to draw conclusions to support any treatment over the other. Multicentre clinical trials are required to compare different treatments for the condition.

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.

Systematic Review and Meta-Analysis on the Management of Open Abdominal Aortic Graft Infections

OBJECTIVE

Aortic graft infection (AGI) is a disastrous complication with an incidence of 0.2-6% in operated patients. With little or no high quality evidence, the best treatment option remains unclear. Therefore, the literature on the management of open abdominal AGI was systematically reviewed to determine optimal treatment.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review and meta-analysis was conducted for AGI. MEDLINE, Embase, and the Cochrane Database of Systematic Reviews were searched. Methodological quality was assessed using the Methodological Index for Non-randomised Studies (MINORS) score. Primary outcomes were 30 day mortality and one year survival. Secondary outcomes were survival, infection recurrence, limb salvage, and graft patency.

RESULTS

Of 1574 studies identified, 32 papers were included in the study. The overall quality of the studies was moderate, with an average MINORS score of 11.9. Pooled overall 30 day mortality and one year survival were 13.5% (95% CI 10.5-16.4) and 73.6% (95% CI 68.8-78.4), respectively. The lowest 30 day mortality and highest one year survival were found for in situ repair compared with extra-anatomic repair and for prosthetic grafts compared with venous grafts or arterial allografts. The infection recurrence rate was highest for prosthetic grafts.

CONCLUSIONS

There is a lack of well designed, qualitative comparative studies making conclusive recommendations impossible. The current best available data suggests that partial graft removal should be avoided and the lowest 30 day mortality and best one year survival are achieved with in situ repair using prosthetic grafts. Initiatives such as the MAGIC database to collaboratively collect prospective data are an important step forward in obtaining more solid answers on this topic.

A Meta-Analysis of Outcomes After In Situ Reconstructions for Aortic Graft Infection

OBJECTIVE

To confirm the advantage of in situ reconstruction (ISR) over extra-anatomic reconstruction (EAR) for aortic graft infection and determine the most appropriate conduit including autogenous veins, cryopreserved allografts, and synthetic prosthesis (standard, rifampicin of silver polyesters).

METHODS

A meta-analysis was conducted with rate of mortality, graft occlusion, amputation, and reinfection. A meta-regression was performed with 4 factors: patients' age, presence of prosthetic-duodenal fistula (PDF), virulent organisms, or nonvirulent organisms.

RESULTS

In situ reconstruction over EAR seems to favor all events. For the 5 conduits used for ISR, according to operative mortality, age of the patients looks to have a positive correlation only for silver polyester and no conduit present any advantage in the presence of PDF. Reinfection seems to be not significantly different for the 5 conduits, and only autogenous veins appear to have a positive correlation with infecting organisms.

CONCLUSION

In situ reconstruction may be considered as first-line treatment. Our results suggest that silver polyesters appear to be most appropriate for older patients, and in order to limit reinfection, autogenous veins are probably the most suitable conduit.

Enxerto aorto bi-ilíaco com veia femoral superficial: uma opção nas infecções de próteses e endopróteses aórticas - relato de caso

Uma das complicações mais temidas na cirurgia vascular é a infecção do enxerto sintético. Afeta 2% dos procedimentos cirúrgicos convencionais e 0,3 a 6% dos procedimentos endovasculares. Relatamos o caso de paciente tratada de aneurisma de aorta abdominal por ambos os métodos e que, após seis anos, foi submetida a retirada das próteses devido à infecção. A veia femoral superficial bilateral foi usada como substituto, com sucesso.

Conservative management of MRSA periaortic graft abscess

Following repair of ruptured abdominal aortic aneurysm a patient developed methicillin-resistant Staphylococcus aureus perigraft abscess. The patient's clinical condition did not permit conventional open surgical correction. Ultrasound-guided aspiration and insertion of percutaneous drain enabled local antibiotic irrigation accompanied by systemic therapy. At 2 years follow-up the patient remains well with no evidence of sepsis.

Ten-year experience in autogenous reconstruction with the femoral vein in the treatment of aortofemoral prosthetic infection

OBJECTIVE

to study the short and long term effectiveness of in situ replacement of infected aortic grafts with the lower extremity deep veins.

METHODS

forty-nine patients operated on for infrarenal aortic graft infection since 1990 were studied. Diagnosis of infection was based on clinical signs, bacteriological tests and typical findings on CT scan and leukocyte scan. The surgical treatment consisted in harvesting the femoral vein, total graft excision, thorough debridement and in situ reconstruction with the femoral veins. After discharge, the patients were followed at 6 monthly intervals with clinical examination, duplex and/or CT scan.

RESULTS

there were four in-hospital deaths (8%). One patient required above-knee amputation (2%) and there were two graft limb occlusions (4%). With a mean follow-up 41 months, another 13 patients died, unrelated to the operation (29%). There were no late amputations and only two late graft limb stenoses (4%). We have a 5 year survival rate of 60%, a 5 year limb salvage rate of 98%, and a 5 year primary patency rate of 91%. There were no cases of aneurysmal dilatation of vein grafts and no incidence of reinfection.

CONCLUSION

in situ reconstruction with the lower extremity deep veins is in the long term a safe and attractive alternative in the treatment of infrarenal aortic graft infection.

Lower intestinal bleeding due to aorto-enteric fistula

The case is described of a man who complained of intermittent fever and fatigue. After three digestive endoscopies and computed tomography, a 99m technetium-HM-PAO-labelled white cell scan was usefully employed to establish diagnosis. Anaerobic aortic Graft infection and anaemia due to lower intermittent occult intestinal bleeding were found. The intestinal bleeding was caused by secondary aorto-jejunal fistula. This condition is rare, but should be suspected whenever a patient with aortic prosthesis presents with occult digestive bleeding and unexplained fever.

Experimental treatment of vascular graft infection due to Staphylococcus epidermidis by in situ replacement with a rifampin-bonded polyester graft

In situ prosthetic graft replacement (ISPGR) of an infected prosthesis raises the risk of recurrent infection in the new graft, especially in cases involving drug-resistant microorganisms. The purpose of this animal study was to evaluate in situ replacement of a vascular graft infected by a highly rifampin-resistant strain of Staphylococcus epidermidis with the use of a rifampin-bonded polyester graft. Antibiotic bonding was obtained by soaking grafts in a high dose of rifampin solution (60 mg/mL). The infrarenal abdominal aorta of 20 dogs was replaced using a polyester prosthesis infected with a highly rifampin-resistant strain of Staphylococcus epidermidis. One week later, the 18 surviving animals were randomized into three groups. Group I (n = 6) did not undergo reoperation. Group II (n = 6) underwent ISPGR using a rifampin-bonded prosthesis. Group III (n = 6) underwent ISPGR using an untreated prosthesis. All surviving animals were killed 28 days after the first procedure. Infectious signs were noted and bacteriological study was carried out on explanted prostheses and various tissue samples. The findings of this experimental study show that soaking a polyester prosthesis in a high-dose rifampin solution can prevent reinfection after in situ replacement of a prosthesis infected by a highly rifampin-resistant Staphylococcus epidermidis.

Endovascular grafting of traumatic aortic aneurysms in contaminated fields

PURPOSE

To evaluate the potential of endovascular stent-grafts to treat traumatic aortic lesions in contaminated areas.

METHODS

Four patients (3 women; ages 26-78 years) underwent stent-grafting to repair an aortic rupture sustained in a motorcycle accident, aortic lacerations secondary to surgical treatment of spondylitis in 2 patients, and an aortobronchial fistula following surgical thoracic aortic repair 10 years earlier. Stent-grafts (2 Corvita, 1 Talent, and 1 Vanguard) were placed endoluminally into the infected areas via a transfemoral approach. Follow-up included erythrocyte sedimentation rate, white blood count, C-reactive protein, blood cultures, and computed tomography (CT).

RESULTS

The stent-grafts were successfully placed in all cases and excluded the aortic lesion. Under supportive antibiotic therapy, inflammation parameters returned to normal. CT imaging showed no evidence of paraprosthetic infection, nor were there any other complications over a follow-up that ranged from 3 to 34 months.

CONCLUSIONS

Endovascular therapy may be an alternative in the acute management of aortic ruptures in the setting of infection. Long-term results are required for definitive evaluation of the method.

Optimization of the resistance of arterial allografts to infection: comparative study with synthetic prostheses

Arterial allografts can be used for in situ treatment of prosthetic graft infection. The purpose of this in vitro study was to compare the resistance of allografts and synthetic prostheses to infection by five strains of bacteria and to study antibiotic treatments designed to reduce allograft infection. Fresh and cryopreserved allografts were compared with synthetic prostheses made of various biomaterials including PTFE, plain Dacron, gelatine-sealed Dacron, and gelatine-sealed, rifampicine-bonded Dacron. Allografts were used with or without treatment using an antibiotic containing gentamycine, lincomycine, and vancomycine. The bacterial strains tested were Escherichia coli, Staphylococcus aureus, slime-producing Staphylococcus epidermidis, non-slime-producing Staphylococcus epidermidis, and Pseudomonas aeruginosa. Infection was evaluated by counting the number of adherent bacteria on the allograft or synthetic material after rinsing and ultrasonication. Statistical analysis was achieved using nonparametric Mann-Whitney tests. Results showed that allografts not treated with antibiotics were highly susceptible to bacterial infection. Antibiotic treatment decreased infection. Application of antibiotic after thawing cryopreserved allografts led to a significant decrease. None of the biomaterials tested provided sufficient protection against bacteria resistant to the antibiotics used.

Thoracoabdominal bypass graft with liver retransplantation for the treatment of a pseudoaneurysm of the supraceliac aorta after liver transplantation

Pseudoaneurysm following liver transplantation is a rare but life-threatening complication. Treatment is directed towards control of fatal bleeding. Ligation with or without revascularization of the graft is the treatment of choice. When revascularization is not possible, or the liver does not tolerate the arterial blood deprivation, retransplantation is the only option. We report a case of a 14-month-old girl who developed a pseudoaneurysm at the anastomosis between the recipient supraceliac aorta and the donor graft. The pseudoaneurysm was excised and the aorta was ligated above and below it. An extra-anatomical thoracoabdominal arterial graft was used to provide arterial blood supply to the lower torso and also to arterialize a new orthotopic liver graft. This is the first reported case of the use of thoracoabdominal jump graft to vascularize a transplanted liver.

Management of synchronous infrarenal aortic disease and large bowel cancer: a North-east of Scotland experience

OBJECTIVES

to review our experience of combined aortic and colonic surgery.

DESIGN

retrospective review.

METHODS

synchronous aortic and colorectal procedures were identified from prospective computerised audit and archival vascular records. Clinical parameters were used as surrogates for measuring clinical outcome.

RESULTS

six patients (F:M=2:1), median age 75.6 years (range 70-80 years) were identified with infrarenal aortic pathology (5 aneurysms, median AP diameter 6 cm, 1 occluded aortoiliac segment) and colonic carcinoma. All carcinomas were Dukes stage B and moderately well differentiated. Synchronous aortic and colonic resections were performed in five cases, bypass for aortoiliac occlusion was deferred in preference to colonic resection in one case. Operating time ranged between 3-6.5 hours (median 4 h), transfusion requirements 2-5 units (median 3 units). One anastomotic dehiscence was reported. With follow-up between 6 months to 6 years all patients remain alive; no patient has re-presented with graft sepsis or symptomatic tumour recurrence.

CONCLUSION

synchronous resections of aortic and colonic lesion may be a treatment option in selected cases.

Bacterial translocation in patients undergoing abdominal aortic aneurysm repair

BACKGROUND

Bacterial translocation occurs in humans and is associated with an increased incidence of septic morbidity. The aims of this study were to determine the prevalence of bacterial translocation in patients undergoing open abdominal aortic aneurysm (AAA) repair and to identify any association with postoperative septic complications.

METHODS

This was a prospective observational study in which patients undergoing aneurysm repair were assessed for evidence of bacterial translocation by culture of a mesenteric lymph node (MLN), small bowel serosal exudate and thrombus within the aneurysm. All postoperative septic complications were recorded.

RESULTS

A total of 51 patients was studied (40 men, 11 women; median age 72 years). Enteric bacteria were isolated from the MLNs of five patients (prevalence of bacterial translocation 10 per cent), one of whom also yielded growth from the serosal exudate. Septic morbidity occurred in four of five patients in whom bacterial translocation was identified, compared with nine of 46 in those without translocation (P = 0.013, Fisher's exact test, mid P). One patient in whom Escherichia coli was grown from the MLN developed an aortoenteric fistula, with a coliform species isolated from the graft.

CONCLUSION

This study suggests that bacterial translocation occurs in patients undergoing AAA repair. It is associated with an increased incidence of postoperative septic morbidity and provides a possible mechanism for infection of prosthetic aortic grafts.

Oral health of patients scheduled for elective abdominal aortic correction with prosthesis

OBJECTIVE

to evaluate the frequency of potential oral foci of infection in patients scheduled for elective abdominal aortic surgery.

DESIGN

prospective clinical study.

MATERIALS

oral health and dentures of 50 patients (33 males and 17 females, mean age 65 years) were examined before aortic surgery.

CHIEF OUTCOME MEASURES

radiographic and clinical examination with special emphasis on identifying acute and chronic oral and ontogenic conditions which may contribute to aortic prosthesis infection.

RESULTS

eighty-two per cent of the patients had some oral infection foci. The mean number of remaining teeth in the cohort was 9.3, and 21% of these were potential infectious foci (62% in the patients). Twenty-six per cent of the patients suffered from oral Candida infection. Seventy-four per cent of the patients had total or partial dentures, 45% of which were ill-fitting and needed repair.

CONCLUSIONS

oral infectious foci occur frequently in patients needing aortic surgery. Untreated foci may contribute to aortic prosthesis infection. Preoperative oral evaluation and elimination of intraoral infection is recommended for patients scheduled for abdominal aortic repair.

Improved management of infrainguinal bypass graft infection with methicillin-resistant Staphylococcus aureus

BACKGROUND

There is considerable debate over the management of infected infrainguinal grafts. This report describes recent experience in this field and documents the change in clinical practice needed to deal with methicillin-resistant Staphylococcus aureus (MRSA).

METHODS

All infected infrainguinal grafts between January 1991 and July 1997 were reviewed. In the light of the findings, clinical practice was modified considerably. A further 1 year was audited prospectively up to August 1998.

RESULTS

Twenty-six patients were treated for 27 infrainguinal graft infections (25 prosthetic, two vein). Twenty were treated by complete graft excision as the initial therapy; graft preservation was attempted in six patients. Before 1995, the infecting organisms were predominantly Pseudomonas aeruginosa or methicillin-sensitive staphylococci. Subsequently all 14 patients treated up to 1997 had infection with MRSA. The overall amputation rate was 17 of 26; ten amputations were in patients with MRSA. Four patients died, all with MRSA sepsis. As a result of this experience a policy of complete isolation was adopted for all patients infected with MRSA. In the 12 months since this policy was introduced, 77 infrainguinal grafts (61 vein, 16 prosthetic) have been inserted. Two grafts (3 per cent) have become infected, necessitating graft excision and amputation.

CONCLUSION

MRSA infection of an infrainguinal graft is a serious complication with high associated amputation and mortality rates. Isolation and barrier nursing appeared to contain the problem.

In situ replacement of infected aortic grafts with rifampicin-bonded prostheses: the Leicester experience (1992 to 1998)

PURPOSE

Prosthetic graft infection after aortic aneurysm surgery is a life-threatening complication. Treatment options include total graft excision and extra-anatomic bypass grafting or in situ replacement of the graft. The latter option is gaining increasing popularity, but the long-term outcome remains uncertain, particularly in light of the increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA). We performed a prospective nonrandomized study to assess the outcome after graft excision and in situ replacement with a rifampicin-bonded prosthesis for the treatment of major aortic graft infection.

METHODS

In a 6-year period from January 1992 to December 1997, 11 patients (eight men, three women) with major aortic graft infection underwent total graft excision and in situ replacement with a rifampicin-bonded prosthesis. The median age of the patients was 66 years (range, 49 to 78 years). Four patients had a hemorrhage from an aortoenteric fistula, three had a retroperitoneal abscess, two had graft occlusion, one had a perigraft collection shown by means of computed tomography, and one had a ruptured suprarenal false aneurysm. Organisms were cultured from 10 patients.

RESULTS

MRSA was isolated in two patients, both of whom had originally undergone repair of a ruptured abdominal aortic aneurysm. Two patients died (18.2%) within 30 days, and three patients (27.6%) had nonfatal complications (peritoneal candidiasis, transient renal impairment, and profound anorexia). Two patients died late in the follow-up period. Seven patients remain alive and clinically free of infection.

CONCLUSION

The long-term results after total graft excision and in situ replacement with a rifampicin-bonded prosthesis appear to be favorable. However, MRSA aortic graft infection appears to be associated with a poor prognosis.

Cryopreserved arterial allografts in the treatment of major vascular infection: a comparison with conventional surgical techniques

OBJECTIVE

Recent findings with cryopreserved heart valve allografts in the treatment of infectious endocarditis suggest that the use of cryopreserved arterial allografts may improve the outcome in patients with vascular infections.

METHODS

Seventy-two patients with mycotic aneurysms (n = 29) or infected vascular prostheses (n = 43) of the thoracic (n = 26) or abdominal aorta (n = 46) were treated with in situ repair and extra-anatomic reconstruction using prosthetic material (n = 38) or implantation of a cryopreserved arterial allograft (n = 34). Disease-related survival and survival free of reoperation were assessed. Morbidity, cumulative lengths of intensive care, hospitalization, antibiotic treatment, and costs were calculated per year of follow-up.

RESULTS

The use of cryopreserved arterial allografts was superior to conventional surgery in terms of disease-related survival (P =.008), disease-related survival free of reoperation (P =.0001), duration of intensive care per year of follow-up (median 1 vs 11 days; range 1 to 42 vs 2 to 120 days; P =.001), hospitalization (14 vs 30 days; range 7 to 150 vs 15 to 240 days; P =.002), duration of postoperative antibiotic therapy (21 vs 40 days; range 21 to 90 vs 60 to 365 days; P =.002), incidence of complications (24% vs 63%; P =.005), and elimination of infection (91% vs 53%; P =.001). In addition, costs were 40% lower in the group treated by allografts (P =.005).

CONCLUSIONS

The use of cryopreserved arterial allografts is a more effective treatment for mycotic aneurysms and infected vascular prostheses than conventional surgical techniques.