Cryopreserved Cadaveric Arterial Allograft for Arterial Reconstruction in Patients with Prosthetic Infection

Evaluation of Autologous Venous Allograft for Lower Limb in the Treatment of Critical Limb Ischemia. The REVATEC (REVAscularisation Par Greffons Veineux BioproTEC) Study

BACKGROUND

Critical limb threatening ischemia (CLTI) requires revascularization whenever it is possible. The great saphenous vein represents the surgical conduit of choice. However, it is not always available, in particular in multi-operated patients. In such cases, alternative efficient biological conduits are needed but data remains limited. This study aims at evaluating the performance of cold stored venous allografts provided by Bioprotec® society.

METHODS

Prospective multi-center cohort. The primary endpoint was limb salvage rate at 1 year following revascularization with cold stored venous allografts. Follow-up based on clinical examination and duplex-scan. Uni- and multivariate analyses were performed to analyze predictive factors of endpoints.

RESULTS

Overall, 39 patients (40 limbs) were included between 2018 and 2021. Patients had a median of 2 [0-6] revascularizations prior to inclusion. A total of 97 grafts were used (median of 3 [1-4] grafts per procedure). In the postoperative period (30 days) no death and 4 major amputations were noted. The median length of follow-up was 13.4 [0.7-31.1] months. The 6-months, 1-year and 2-year freedom from major amputation rates were 79% [95% CI: 68-93], 75% (95% CI 62%-91%) and 68% [95% CI: 51-90], respectively. The 6 months, 1-year and 2-year survival rates were 95% [88-100], 83% [95% CI: 71-98] and 79% [95% CI: 65-96], respectively. Primary patency rates were 77% [95% CI: 64-91] at 6 months, and 47% [95% CI: 32-70] at one and 2 years. Secondary patency rates were 82% [95% CI: 70-95] at 6 months and 50% [95% CI: 34-73] at one and 2 years. The analysis identified the number of previous revascularizations as a significant risk factor for graft patency (Hazard Ratio: 1.59; 95% Confidence Interval: 1.13-2.24).

CONCLUSION

Revascularization of CLTI patients with previous failed interventions is highly challenging. The use of cold stored venous allograft showed encouraging limb salvage rate despite modest patency rates and thus may represent an alternative to other substitute in some selected cases. More studies are necessary to identify the potential of CSVA in CLTI patients.

Outcomes of native or graft abdominal aortic infection managed with orthotopic xeno pericardial grafts or cryopreserved allograft: A French bicentric comparative study

BACKGROUND

The ideal substitute for in situ reconstruction of aortic graft or native aortic infection has yet to be defined. Though recognized as resistant to infection, cryopreserved arterial allograft (Allograft) presents problems of availability when treating emergent cases, with the risk of long-term aneurysmal degeneration. Commercially available bovine pericardial substitutes (Pericard) seems to be an alternative, with promising results in the recent literature. The goal of this study was to compare the results of these two substitutes.

METHODS

Between January 2010 and December 2023, we conducted a retrospective observational study in two tertiary centers, including all patients having undergone in situ surgery for aortic graft or native aortic infections with reconstruction by Allograft or Pericard. Survival, reinterventions and reinfections were analyzed according to the Kaplan-Meier method and Cox regression model.

RESULTS

All in all, 169 patients were included in the study with 103 aortic graft infections (60.9%), 33 aortic endograft infections (19.5%), and 33 native aortic infections (19.5%). Allograft was used in 111 patients (65.7%) and Pericard in 58 (34.3%). The two groups were comparable as regards preoperative risk factors, types of index surgery, and infectious agents, with 41 patients (24.8%) with an aortoenteric fistula. There was no significant difference in postoperative complications. The median follow-up was 18 months (interquartile range, 4-44 months). At 24 months, survival was comparable, with 68 ± 4% for Allograft and 68 ± 6 for Pericard, as was reinfection-free survival with 80 ± 4% for Allograft vs 83 ± 6% for Pericard (P = .722). Reintervention-free survival at 2 years was likewise comparable: 86 ± 4% for Allograft vs 77 ± 8% for Pericard (P = .419).

CONCLUSIONS

A pericardial substitute offers the possibility of in situ aortic reconstruction without the problems of availability and with midterm results comparable with those achieved with aortic allografts. Further studies with long-term follow-up are needed to validate the absence of late reinfection and to confirm pericardial substitute patency.

Contemporary Experience of the Neo-Aortoiliac System (NAIS) Procedure: A Case Series with Review of the Literature

OBJECTIVES

Aortic graft infection (AGI) is a life-threatening complication that can result in death, amputation, sepsis, aorto-enteric fistula, and pseudoaneurysm formation. After explantation of the infected graft, options for reconstruction include extra-anatomic bypass or in-line reconstruction using antibiotic-coated prosthetic graft, cryopreserved allograft, or a neo-aortoiliac system (NAIS) using autogenous femoral veins. While the NAIS procedure has shown promising results, there is relatively limited clinical experience due the magnitude and morbidity of the surgery. In this study, we reviewed our single-center experience using the NAIS procedure and performed a systematic review of the contemporary literature more than the past decade.

METHODS

A retrospective review was performed on all patients undergoing NAIS reconstruction with autogenous femoral vein conduits at a single institution from 2010 to 2022. Pubmed, Embase, and Cochrane Library databases were queried for studies published from 2012 to 2022 to identify those reporting on outcomes of patients undergoing the NAIS procedure. Outcome variables included early and late mortality, major complications including amputation, graft or conduit related complications, re-infection, and re-intervention. Additional variables collected include patient demographics, operative technique, and follow up.

RESULTS

There were 14 patients included in our case series with 30-day mortality of 21%. At a mean follow up of 22 months, complication rate was 64.3%, re-intervention rate was 14.3%, re-infection rate was 7.1%, and amputation rate was 7.1%. On review of the literature, 12 studies ultimately met criteria to be included in analysis with a combined total of 368 patients. Pooled averages included 30-day mortality of 9.0%, re-intervention rate of 20.5%, re-infection rate of 5.6%, and amputation rate of 6.5%.

CONCLUSIONS

The NAIS procedure for management of AGI is a formidable procedure with significant early mortality and morbidity. This treatment should be considered in the context of other revascularization options for management of an AGI.

Early and severe aortic endograft infection after percutaneous coil embolization of type 2 endoleak: A case report

INTRODUCTION

Endovascular aneurysm repair for abdominal aortic aneurysm is superior to open surgery regarding perioperative morbidity and mortality. Complications such as endoleaks represent a significant source of secondary intervention. Vascular graft infection is another serious complication found in 0.2 to 1 % of series. We hereby describe a case of a rapidly progressive aortic infection by Cutibacterium acnes following a percutaneous embolization procedure for a type II endoleak.

CASE PRESENTATION

A 75-year-old man presented with a fever along with lower back and buttock pain five days after embolization via direct percutaneous puncture for a type II endoleak. White blood cell scintigraphy and blood culture suggested the presence of aortitis, but the patient experienced notable spontaneous improvement in both clinical symptoms and biological markers. The patient underwent CT-angiography which revealed aneurysm rupture requiring urgent open surgery and initiation of antimicrobial therapy. Similarly to blood cultures, per-operative aortic wall tissue samples also revealed presence of Cutibacterium acnes.

DISCUSSION

Aortic endograft infection after embolization is an uncommon complication. The diagnosis is based on a combination of imaging, blood, and nuclear tests. Repeated CT-angiography may be helpful when infection occurs quickly after embolization. Staphylococcus and Streptococci are common pathogens implicated in these infections.

CONCLUSIONS

This is a case of an early and severe aortic endograft infection after percutaneous coil embolization of type 2 endoleak. Rupture occurred in less two weeks despite a slow-growing organism infection. The treatment includes endograft removal and antibacterial therapy. Caution is warranted when suspecting aortic endoprosthesis infection, necessitating close follow-up.

Early and Mid-Term Results of Native and Abdominal Aortic Graft Infection Treatment via Surgeon-Constructed Porcine Pericardial Aortic Tubes

The search for optimal material for aortic infection reconstruction is ongoing. Our study presents the early and mid-term results of surgeon-constructed porcine pericardial tubes in the in-situ reconstruction of abdominal aortic infections, focusing on the safety as well as the durability of surgeon-created tubes. We performed a retrospective analysis of 8 patients treated for native aortic (n = 3) and aortic graft infections (n = 5) with surgeon-created tubes made of porcine pericardium patch (8 × 14 cm NO-REACT Ⓡ, BioIntegral Surgical Inc., Mississauga, ON, Canada). There were 7 males and 1 female, aged 68.5 (±4.8 years). Three patients had an aorto-enteric fistula. Technical success was obtained in all patients. Thirty-day mortality was 12.5% (n = 1). Mid-term follow-up was 12 months (2-63 months). One-year mortality was 37.5% (n = 3). Reintervention rate was 28.5% (n = 2). False aneurysm rate in the follow-up was 14.2% (n = 1). Surgeon-constructed porcine pericardial tubes seem to be a promising alternative as a replacement for native as well as graft-related abdominal aortic infections. The mid-term durability is encouraging, once the infection is controlled in cases with successful fistula repair and in native aortic infections patients. Further observations on larger groups, in longer follow-ups are necessary to confirm these preliminary observations.

Contemporary outcomes for arterial reconstruction with non-saphenous vein cryo-preserved conduits

OBJECTIVE

Cryopreserved (CP) products are utilized during challenging cases when autogenous or prosthetic conduit use is not feasible. Despite decades of experience with cadaveric greater saphenous vein (GSV), there is limited available data regarding the outcomes and patency of other CP products, specifically arterial and deep venous grafts. This study was designed to evaluate outcomes of non-GSV CP conduits in patients undergoing urgent, emergent, and elective arterial reconstruction at our institution. We hypothesized that non-GSV CP allografts have adequate patency and outcomes and are therefore a feasible alternative to GSV in settings where autologous graft is unavailable or prosthetic grafts are contraindicated.

METHODS

This study was approved by the Institutional Review Board at our institution. We retrospectively reviewed charts of patients undergoing arterial reconstructions using CP conduits from 2010 to 2022. Data collected included demographics, comorbidities, smoking status, indications for surgery, indication for CP conduit use, anatomic reconstruction, urgency of procedure, and blood loss. Time-to-event outcomes included primary and secondary graft patency rates, follow-up amputations, and mortality; other complications included follow-up infection/reinfection and 30-day complications, including return to the operating room and perioperative mortality. Time-to-event analyses were evaluated using product-limit survival estimates.

RESULTS

Of 96 identified patients receiving CP conduits, 56 patients received non-GSV conduits for 66 arterial reconstructions. The most common type of non-GSV CP product used was femoral artery (31 patients), followed by aorto-iliac artery (22 patients), and femoral vein (19 patients), with some patients receiving more than one reconstruction or CP product. Patients were mostly male (75%), with a mean age of 63.1 years and a mean body mass index of 26.7 kg/m2. Indications for CP conduit use included infection in 53 patients, hostile environment in 36 patients, contaminated field in 30 patients, tissue coverage concerns in 30 patients, inadequate conduit in nine patients, and patient preference in one patient. Notably, multiple patients had more than one indication. Most surgeries (95%) were performed in urgent or emergent settings. Supra-inguinal reconstructions were most common (53%), followed by extra-anatomic bypasses (47%). Thirty-day mortality occurred in 10 patients (19%). Fifteen patients (27%) required return to the operating room for indications related to the vascular reconstructions, with 10 (18%) cases being unplanned and five (9%) cases planned/staged. Overall survival at 6, 12, and 24 months was 80%, 68%, and 59%, respectively. Primary patency at 6, 12, and 24 months was 86%, 70%, and 62%, respectively. Amputation freedom at 6 months, 12 months, and 24 months was 98%, 95%, and 86%, respectively for non-traumatic indications.

CONCLUSIONS

Non-GSV CP products may be used in complex arterial reconstructions when autogenous or prosthetic options are not feasible or available.

Use of Omniflow® II Biosynthetic Graft for the Treatment of Vascular Graft and Endograft Infections

BACKGROUND

Vascular graft/endograft infection is a rare but life-threatening complication of cardiovascular surgery and remains a surgical challenge. Several different graft materials are available for the treatment of vascular graft/endograft infection, each having its own advantages and disadvantages. Biosynthetic vascular grafts have shown low reinfection rates and could be a potential second best after autologous veins in the treatment of vascular graft/endograft infection. Therefore, the aim of our study was to evaluate the efficacy and morbidity of Omniflow® II for the treatment of vascular graft/endograft infection.

METHODS

A multicenter retrospective cohort study was performed to evaluate the use of Omniflow® II in the abdominal and peripheral region to treat vascular graft/endograft infection between January 2014 and December 2021. Primary outcome was recurrent vascular graft infection. Secondary outcomes included primary patency, primary assisted patency, secondary patency, all-cause mortality, and major amputation.

RESULTS

Fifty-two patients were included with a median follow-up duration of 26.5 (10.8-54.8) months. Nine (17%) grafts were implanted in intracavitary position and 43 (83%) in peripheral position. Most grafts were used as femoral interposition (n = 12, 23%), femoro-femoral crossover (n = 10, 19%), femoro-popliteal (n = 8, 15%), and aorto-bifemoral (n = 8, 15%) graft. Fifteen (29%) grafts were implanted extra-anatomically and 37 (71%) in situ. Eight patients (15%) presented with reinfection during follow-up, most of these patients received an aorto-bifemoral graft (n = 3, 38%). Intracavitary vascular grafting had a 33% (n = 3) reinfection rate and peripheral grafting 12% (n = 5; P = 0.025). The estimated primary patencies at 1, 2, and 3 years were 75%, 72%, and 72% for peripherally located grafts and 58% (at all timepoints) for intracavitary grafts (P = 0.815). Secondary patencies at 1, 2, and 3 years were 77% (at all timepoints) for peripherally located prostheses and 75% (at all timepoints) for intracavitary prostheses (P = 0.731). A significantly higher mortality during follow-up was observed in patients who received an intracavitary graft compared to patients with a peripheral graft (P = 0.003).

CONCLUSIONS

This study highlights the efficacy and safety of the Omniflow® II biosynthetic prosthesis for the treatment of vascular graft/endograft infection, in absence of suitable venous material, with acceptable reinfection, patency, and freedom of amputation prevalences, especially in replacing peripheral vascular graft/endograft infection. However, a control group with either venous reconstruction or another alternative graft is needed to make firmer conclusions.

Aortic Endograft Infection: Diagnosis and Management

Aortic endograft infection (AEI) is a rare but life-threatening complication of endovascular aneurysm repair (EVAR). The clinical features of AEI range from generalized weakness and mild fever to fatal aortic rupture or sepsis. The diagnosis of AEI usually depends on clinical manifestations, laboratory tests, and imaging studies. Management of Aortic Graft Infection Collaboration (MAGIC) criteria are often used to diagnose AEI. Surgical removal of the infected endograft, restoration of aortic blood flow, and antimicrobial therapy are the main components of AEI treatment. After removing an infected endograft, in situ aortic reconstruction is often performed instead of an extra-anatomic bypass. Various biological and prosthetic aortic grafts have been used in aortic reconstruction to avoid reinfection, rupture, or occlusion. Each type of graft has its own merits and disadvantages. In patients with an unacceptably high surgical risk and no evidence of an aortic fistula, conservative treatment can be an alternative. Treatment results are determined by bacterial virulence, patient status, including the presence of an aortic fistula, and hospital factors. Considering the severity of this condition, the best strategy is prevention. When encountering a patient with AEI, current practice emphasizes a multidisciplinary team approach to achieve an optimal outcome.

Performance of the BioIntegral Bovine Pericardial Graft in Vascular Infections: VASCular No-REact Graft Against INfection Study

BACKGROUND

Vascular graft and endograft infections (VGEI) and native vessel infections (NVI) remain considerable challenges in vascular surgery, leading to high mortality and morbidity rates. Although in situ reconstruction is the preferred treatment, the material of choice is still a source of debate. Autologous veins are considered the first choice; however, xenografts may be an acceptable alternative. The performance of a biomodified bovine pericardial graft is assessed when implemented in an infected vascular area.

METHODS

This is a prospective multicenter cohort study. Patients who underwent reconstruction for VGEI or NVI with a biomodified bovine pericardial bifurcated or straight tube graft were included from December 2017 until June 2021. The primary outcome measure was reinfection at mid-term follow-up. Secondary outcome measures included mortality, patency, and amputation rate.

RESULTS

Thirty-four patients with vascular infections were included, of which 23 (68%) had an infected Dacron prosthesis after primary open repair and 8 (24%) had an infected endovascular graft. The remaining 3 (9%) had infected native vessels. At secondary repair, 3 (7%) patients had an in situ aortic tube reconstruction, 29 (66%) had an aortic bifurcated reconstruction, and 2 (5%) had an iliac-femoral reconstruction. At 1-year follow-up after the BioIntegral bovine pericardial graft reconstruction, the reinfection rate was 9%. The 1-year infection-related and procedure-related mortality rate was 16%. The occlusion rate was 6% and in total 3 patients underwent a lower limb amputation during the 1-year follow-up period.

CONCLUSIONS

In situ reconstruction as treatment of (endo)graft and native vessel infections remains a challenge and reinfection looms as a potential consequence. In cases where time is of essence or when autologous venous repair is not feasible, a swift available solution is needed. The BioIntegral biomodified bovine pericardial graft may be an option as it shows reasonable results in terms of reinfection, in aortic tube and bifurcated grafts.

A case of mycotic infrarenal abdominal aortic aneurysm after bacillus Calmette-Guérin immunotherapy for bladder cancer and a review of the literature

A 69-year-old patient presented with a 9-month history of constitutional symptoms and a 3-week history of increasing abdominal and back pain. He had a history of bacillus Calmette-Guérin immunotherapy for bladder cancer 9 months earlier. An infrarenal mycotic aneurysm was detected by positron emission tomography-computed tomography. His abdominal aorta was reconstructed using a tube graft tailored from a bovine pericardium sheet. We chose this graft because of its acellular nature and reduced risk of postoperative infection. The culture from the aortic wall yielded acid fast bacilli, and he was treated with antituberculosis medication. His postoperative recovery was uneventful, except for chylous ascites.

Peripheral vascular bypass with cadaveric arterial allograft in a toddler with femoral mycotic aneurysm

Mycotic aneurysms are exceedingly rare in the pediatric population. The optimal surgical treatment for children with this disease is unclear as aneurysm resection and vascular reconstruction are uncommonly performed in young children. We present a unique case of a 21-month-old child with a complex cardiac history who presented with limb ischemia and was discovered to have thrombosis of the common femoral and superficial femoral artery. Groin exploration revealed a left common femoral and superficial femoral artery mycotic aneurysm that was successfully repaired with excision of the mycotic aneurysm, external iliac to profunda femoral artery vascular bypass using cryopreserved arterial allograft and femoral vein reconstruction. This case demonstrates successful vascular reconstruction can be performed in a young child with an Aspergillus mycotic aneurysm using cadaveric arterial allograft.

Infection of Vascular Prostheses: A Comprehensive Review

Vascular graft or endograft infection (VGEI) is a complex disease that complicates vascular-surgery and endovascular-surgery procedures and determines high morbidity and mortality. This review article provides the most updated general evidence on the pathogenesis, prevention, diagnosis, and treatment of VGEI. Several microorganisms are involved in VGEI development, but the most frequent one, responsible for over 75% of infections, is Staphylococcus aureus. Specific clinical, surgical, radiologic, and laboratory criteria are pivotal for the diagnosis of VGEI. Surgery and antimicrobial therapy are cornerstones in treatment for most patients with VGEI. For patients unfit for surgery, alternative treatment is available to improve the clinical course of VGEI.

Ten-year experience with cryopreserved vascular allografts in the Croatian Cardiovascular Tissue Bank

The Croatian Cardiovascular Tissue Bank (CTB) was established in June 2011. Activities managed by CTB are processing of heart valves and blood vessels, as well as quality control, storage, medical release and distribution of allografts. The aim of this report is to present CTB's vascular tissue activities and retrospectively evaluate the outcomes of their use in the University Hospital Centre Zagreb. Between June 2011 and July 2021, 90 vascular allografts (VAs) from 55 donors after brain death were referred to CTB. Only 54% of VAs met the tissue quality requirements while 46% of tissues were discarded. The most frequent reasons for discard were unacceptable morphology and initial microbiological contamination. Altogether 42 VAs were released for transplantation and 37 of them were used in 27 surgical procedures. The most common indication for surgery was prosthetic graft or stent infection. According to the anatomic position of vascular reconstruction, patients were divided in the aortic and peripheral reconstruction group. A total of 23 patients were treated. In the aortic reconstruction group 58% of patients did not experience any graft-related complications. In the group of patients who underwent peripheral reconstruction significant incidence of reinfection was observed highlighting it as a major graft-related complication. Despite the small patient groups and limited duration of follow-up, presented clinical outcomes provide valuable information on the efficacy of vascular allografts. Additional clinical results collected on a larger patient groups and comparison to other reconstructive treatment options are necessary.

Comparison of arterial and venous allograft bypass in chronic limb-threatening ischemia

INTRODUCTION

Femoro-popliteal bypass with autologous vascular graft is a key revascularization method in chronic limb-threatening ischemia (CLTI). However, the lack of suitable autologous conduit may occur in 15-45% of the patients, necessitating the implantation of prosthetic or allogen grafts. Only little data is available on the outcome of allograft use in CLTI.

AIMS

Our objective were to evaluate the long term results of infrainguinal allograft bypass surgery in patients with chronic limb-threatening ischemia (CLTI) and compare the results of arterial and venous allografts.

METHODS

Single center, retrospective study analysing the outcomes of infrainguinal allograft bypass surgery in patients with CLTI between January 2007 and December 2017.

RESULTS

During a 11-year period, 134 infrainguinal allograft bypasses were performed for CLTI [91 males (67.9%)]. Great saphenous vein (GSV) was implanted in 100 cases, superficial femoral artery (SFA) was implanted in 34 cases. Early postoperative complications appeared in 16.4% of cases and perioperative mortality (<30 days) was 1.4%. Primary patency at one, three and five years was 59%, 44% and 41%, respectively, while secondary patency was 60%, 45% and 41%, respectively. Primary patency of the SFA allografts was significantly higher than GSV allografts (1 year: SFA: 84% vs. GSV: 51% p = 0,001; 3 years: SFA: 76% vs. GSV: 32% p = 0,001; 5 years: SFA: 71% vs. GSV: 30% p = 0.001). Both primary and secondary patency of SFA allograft implanted in below-knee position were significantly higher than GSV bypasses (p = 0.0006; p = 0.0005, respectively). Limb salvage at one, three and five years following surgery was 74%, 64% and 62%, respectively. Long-term survival was 53% at 5 years.

CONCLUSION

Allograft implantation is a suitable method for limb salvage in CLTI. The patency of arterial allograft is better than venous allograft patency, especially in below-knee position during infrainguinal allograft bypass surgery.

Obturator bypass remains a useful option

OBJECTIVES

The femoral tripod remains technically crucial in vascular surgery, as well for an elective revascularization as for an extensive approach to the arterial tree. The management of septic complications and healing disorders in this area is really challenging. Obturator bypass (OB) represents an alternative sometimes employed in this context, but few recent series were recently published. The objectives of this work were thus to evaluate the results of OB in terms of patency, morbi-mortality, healing evolution and absence of reinfection.

MATERIAL AND METHODS

This was a monocentric retrospective study including all the patients treated by OB, whatever the cause, between January 2010 and December 2020. Primary outcomes were the primary and the secondary patencies. The secondary outcomes were the morbi-mortality, freedom from infection and healing.

RESULTS

During this period, 23 OBs were carried out in 22 patients, with a majority of men (77%) whose median age was 70 years [34 - 87]. The indications were infection in 19 patients (86%), and iterative thrombosis in three patients (14%). The substitute was an arterial allograft in 82% of the cases, and the outflow was the deep femoral artery only in 14% of the cases. The median operative time was 224 min [111-391] and median blood losses were 900 mL [300-3900]. We observed seven systemic (32%), and eight local complications (36%). Healing was obtained in 90% of the cases, and freedom from infection was obtained in 100% of the cases. The median duration of follow-up was 594 days [5 - 2517]. One-year, two-year and three-year primary patency rates were 84%, 78%, and 63%, respectively. One-year, two-year and three-year secondary patencies were 94%, 94%, and 80%, respectively. One-month, one-year, two-year and three-year survival rates were 86%, 73%, 67%, and 53%, respectively.

CONCLUSION

Our study showed that the OB represents a relevant alternative in the event of complex lesions of the femoral tripod, with good patency and healing rates and good infection control. On the other hand, its consequences in terms of morbi-mortality confirm that OB is a major surgery that should be used when a traditional approach is not possible.

Outcomes of patients with aortic vascular graft and endograft infections initially contra-indicated for complete graft explantation

OBJECTIVE

Complete excision in patients with aortic vascular graft and endograft infections (VGEIs) is a significant undertaking, and many patients never undergo definitive treatment. Knowing their fate is important to be able to assess the risks of graft excision vs alternative strategies. This study analyzed their life expectancy and sepsis-free survival.

METHODS

VGEIs were diagnosed according to the Aortic Graft Infection (MAGIC) criteria, and patients turned down for graft removal from November 2006 to December 2020 were included. Primary endpoints were aortic-related and sepsis-free survival estimated using the Kaplan-Meier method. A Cox proportional hazards regression analysis was used to compute the hazard ratio (HR) and 95% confidence interval (CI) as estimates of survival without sepsis.

RESULTS

Seventy-four patients were included, with a median age of 71 years (range, 63-79 years). The index aortic repair was either open (n = 33; 44.6%), endovascular (n = 19; 25.7%), or hybrid (n = 22; 29.7%). Causative organisms were identified in 56 patients (75.7%). At presentation, 26 patients (35.1%) required salvage surgery, open (n = 22; 29.7%) or endovascular (n = 8; 10.8%), and 17 radiological drainage (23.0%). During follow-up, eight required drainage and 11 (14.9%) graft removal (five complete). Infectious complications included pseudoaneurysms (n = 14; 18.9%), rupture (n = 9; 12.2%), gastro-intestinal bleeding (n = 13; 17.6%), septic embolisms (n = 4; 5.4%), and thrombosis (n = 12; 16.2%). In-hospital mortality was 20.3% (n = 15), freedom from aortic-related death and overall survival was 77.1% (95% CI, 65.2%-85.3%) and 70.4% (95% CI, 58.3%-79.7%) at 1 year, and 61.7% (95% CI, 46.1%-74.0%) and 43.1% (95% CI, 29.2%-56.3%) at 5 years. Sepsis recurrence occurred in 37 patients (50.0%). Seven (16.3%) developed acquired antimicrobial resistance. Malnutrition (HR, 3.3; 95% CI, 1.4-7.6; P = .005), hemorrhagic shock at presentation (HR, 2.9; 95% CI, 1.0-8.2; P = .048), aorto-enteric fistulae (HR, 3.3; 95% CI, 1.3-8.4; P = .011), fungal coinfection (HR, 3.5; 95% CI, 1.2-11.5; P = .030), and infection with resistant micro-organisms (HR, 3.1; 95% CI, 1.1-8.3; P = .023) were significantly associated with worse survival without sepsis.

CONCLUSIONS

In-hospital and aortic-related mortality were significant, but with salvage surgery and antibiotic therapy, the median survival was 3 years. Sepsis recurrence remained frequent, and further procedures were needed. These outcomes should be considered when graft excision is proposed. Known predictors of adverse outcomes should become important points for discussion in multidisciplinary team meetings.

Aneurysmal degeneration of the hood of a cryopreserved vein allograft two years after thrombosis

Cryopreserved vein allografts are used as alternative conduits for infrainguinal bypass but are prone to aneurysmal degeneration. A 60-year-old man presented with a pulsatile, tender right groin mass 2 years after thrombosis of a cryopreserved vein jump graft emanating from a prosthetic axillary to profunda bypass. Intraoperatively, the aneurysm was consistent with isolated dilatation of the hood of the thrombosed cryopreserved vein graft. This was excised and repaired with bovine pericardial patch angioplasty. The patient recovered with no recurrence for 2 years. Aneurysmal degeneration of the cryopreserved vein allograft can occur even after graft thrombosis.

Contemporary results with the biosynthetic glutaraldehyde denatured ovine collagen graft (Omniflow II) in lower extremity arterial revascularization in a septic context

OBJECTIVE

Prosthetic peripheral vascular graft infections are poorly evaluated, despite a grim prognosis with high mortality and major amputation rates. The vascular substitute of choice remains controversial when autologous veins are unavailable. The main objective of this study was to evaluate the mid-term results of a new alternative biosynthetic collagen graft (Omniflow II®) in an infected field in patients with unavailable or unsuitable autologous saphenous vein.

METHODS

This retrospective, observational, multicentric study included all consecutive patients in whom an Omniflow II® graft was used for infra-inguinal revascularization in the context of sepsis from January 2015 to January 2020. The primary endpoint was freedom from major amputation; secondary endpoints were 30-day mortality, perioperative morbidity, and estimated survival, patency, and freedom from reinfection estimated using the Kaplan-Meier method.

RESULTS

Twenty-nine patients (27 men, median age 69 years (IQR:60;76) were included. Fever was present in 58.6% of cases, a septic rupture in 17.9%, and a pseudo-aneurysm in 25.0%. The 30-day mortality rate was 3.4% (septic shock). The median follow-up reached 49 months. At 1 and 3 years, the estimated freedom from major amputation was 88.4% and 83.9%, survival was 96%, primary patency was 74.6% and 65.8%, secondary patency was 82.1% and 77.7% and reinfection free-survival was 85.6%. There were 7 occlusions (1 iliofemoral, 1 below-knee, and 5 above-knee bypasses), 3 explantations for persistent sepsis, 4 reinfections (all within the first 6 months which led to 1 death and 3 major amputations), and a total of 4 major amputations. The risk of major amputation increased with bypass reinfection (p=.004), occlusion (p=.005), and polymicrobial infection (p=.05).

CONCLUSION

In a septic context, the Omniflow II® bioprosthetic graft represents an acceptable vascular substitute in the absence of an autologous vein. It provides acceptable freedom from major amputation and reinfection considering the seriousness of this pathology. This usage remains outside the instructions for use, it is, therefore, essential to pursue longer-term studies in larger cohorts.

Stapled Porcine Pericardium Displays Lower Infectivity In Vitro Than Native and Sutured Porcine Pericardium

BACKGROUND

Biological xenografts using tubulized porcine pericardium are an alternative to replace infected prosthetic graft. We recently reported an innovative technique using a stapled porcine pericardial bioconduit for immediate vascular reconstruction in emergency. The objective of this study is to compare the growth and adherence to grafts of bacteria and yeast incubated with stapled porcine pericardium, sutured or naked pericardium.

MATERIAL AND METHODS

One square centimeter of porcine pericardial patches, with or without staples or sutures, was incubated with 10⁵ colony forming units of Escherichia coli, Staphylococcus aureus, Staphylococcus epidermidis, and Candida albicans for 1, 6, and 24 h. The medium was collected to quantify planktonic microorganisms, while grafts were sonicated to quantify adherent microorganisms. Dacron and Dacron Silver were analyzed in parallel as synthetic reference prostheses.

RESULTS

Stapled porcine pericardium reduced the growth and the adherence of E coli (2- to 30-fold; P < 0.0005), S aureus (11- to 1000-fold; P < 0.0006), S epidermidis (>500-fold; P < 0.0001), and C albicans (12- to 50-fold; P < 0.0001) when compared to medium alone (growth) and pericardium or Dacron (adherence). Native and sutured porcine pericardium interfered with the growth and the adherence of E coli and C albicans, and Dacron with that of S epidermidis. As expected, Dacron Silver was robustly bactericidal.

CONCLUSIONS

Stapled porcine pericardium exhibited a lower susceptibility to infection by bacteria and yeasts in vitro when compared to the native and sutured porcine pericardium. Stapled porcine pericardium might be a good option for rapid vascular grafting without increasing infectivity.

Microbiological assessment of arterial allografts processed in a tissue bank

The transmission of microbial infection through tissue allografts is one of the main risks that must be controlled in tissue banks. Therefore, microbiological monitoring controls and validated protocols for the decontamination of tissues during processing have been implemented. This study is based on the evaluation of data from microbiological cultures of arteries (mainly long peripheral arteries) processed in the tissue bank of Valencia (Spain). Donors' profile, pre- and post-disinfection tissue samples were assessed. The presence of residual antibiotics in disinfected tissues was determined and the antimicrobial potential of these tissues was tested. Our overall contamination rate was 23.69%, with a disinfection rate (after antibiotic incubation) of 87.5%. Most (76.09%) of the microbial contaminants were identified as Gram positive. Arterial allografts collected from body sites affected by prior organ removal showed higher risk of contamination. Only vancomycin was detected as tissue release. The antimicrobial effect on Candida albicans was lower than that for bacterial species. Risk assessment for microbial contamination suggested the donor's skin and the environment during tissue collection as the main sources for allograft contamination. Antibiotic-disinfected arterial allografts showed antimicrobial potential.

Cryopreservation moderates the thrombogenicity of arterial allografts during storage

INTRODUCTION

Management of vascular infections represents a major challenge in vascular surgery. The use of cryopreserved vascular allografts could be a feasible therapeutic option, but the optimal conditions for their production and use are not precisely defined.

AIMS

To evaluate the effects of cryopreservation and the duration of storage on the thrombogenicity of femoral artery allografts.

METHODS

In our prospective study, eleven multi-organ-donation-harvested human femoral arteries were examined at five time points during storage at -80°C: before cryopreservation as a fresh native sample and immediately, one, twelve and twenty-four weeks after the cryopreservation. Cross-sections of allografts were perfused with heparin-anticoagulated blood at shear-rates relevant to medium-sized arteries. The deposited platelets and fibrin were immunostained. The thrombogenicity of the intima, media and adventitia layers of the artery grafts was assessed quantitatively from the relative area covered by fibrin- and platelet-related fluorescent signal in the confocal micrographs.

RESULTS

Regression analysis of the fibrin and platelet coverage in the course of the 24-week storage excluded the possibility for increase in the graft thrombogenicity in the course of time and supported the hypothesis for a descending trend in fibrin generation and platelet deposition on the arterial wall. The fibrin deposition in the cryopreserved samples did not exceed the level detected in any of the three layers of the native graft. However, an early (up to week 12) shift above the native sample level was observed in the platelet adhesion to the media.

CONCLUSIONS

The hemostatic potential of cryopreserved arterial allografts was retained, whereas their thrombogenic potential declined during the 6-month storage. The only transient prothrombotic change was observed in the media layer, where the platelet deposition exceeded that of the fresh native grafts in the initial twelve weeks after cryopreservation, suggesting a potential clinical benefit from antiplatelet therapy in this time-window.

Short and Mid Term Outcomes of Cryopreserved Abdominal Aortic Allografts Used as a Substitute for Infected Prosthetic Grafts in 200 Patients

OBJECTIVE

To investigate the use of cryopreserved arterial allografts (CAA) as a substitute for infected infrarenal aortic prostheses, and its outcomes.

METHODS

A single centre retrospective study of consecutive patients receiving an abdominal aortic CAA after removal of an infected graft was conducted between January 1997 and December 2013. The primary outcome was the rate of allograft related revision surgery. Secondary outcomes were the 30 day mortality rate, survival, primary patency, limb salvage, and infection recurrence. Allograft ruptures secondary to infection and risk factors for allograft failure were also investigated.

RESULTS

Two hundred patients (mean age 64.2 ± 9.4 years) were included. In 56 (28%) cases, infection was related to an enteric fistula. The mean follow up duration was 4.1 years. The 30 day mortality rate was 11%. Early revision surgery was needed in 59 patients (29.5%). Among them, 15 (7.5%) were allograft related and led to the death of three patients (1.5%), corresponding to a 7.5% 30 day allograft related revision surgery rate. During the first six months, 17 (8.5%) patients experienced 21 events with complete or partial rupture (pseudo-aneurysm) of the allograft responsible for five (2.5%) deaths, corresponding to a re-infection rate of 8.5%. The multivariable analysis showed that diabetes and pseudo-aneurysm of the native aorta on presentation were predictive factors for short term allograft rupture. After six months, 25 (12.5%) patients experienced long term allograft complications (rupture, n = 2, 1%; pseudo-aneurysm, n = 6, 3%; aneurysm, n = 2, 1%; thrombosis, n = 11, 5.5%; stenosis, n = 4, 2%;) requiring revision surgery resulting in one death. The five year rates of survival, allograft related revision surgery, limb salvage, primary patency, and infection recurrence were 56%, 30%, 89%, 80%, and 12%, respectively.

CONCLUSION

CAAs provide acceptable results to treat aortic graft infection with few early graft related fatal complications. Long term allograft related complications are quite common but are associated with low mortality and amputation rates.

Long-term results of cryopreserved allografts in aortoiliac graft infections

OBJECTIVE

Different graft materials have been proposed for in situ reconstruction in the setting of vascular graft infection (VGI). We analyzed the long-term outcomes after in situ aortoiliac reconstruction with cryopreserved allografts.

METHODS

We performed a retrospective analysis of patients who had undergone in situ aortoiliac reconstruction with cryopreserved arterial allografts for VGI from 2000 to 2015. The end points were the perioperative and long-term mortality and graft-related complications, including stenosis, occlusion, pseudoaneurysm, and reinfection.

RESULTS

A total of 33 patients (91% male) with a median age of 67 years (range, 53-83 years) had undergone in situ aortoiliac reconstruction with cryopreserved allografts. The 30-day mortality was 6% (n = 2); both deaths were related to the allograft (one early allograft-enteric fistula and one graft rupture). Another two patients had experienced early (≤30 days) graft-related events (one allograft-enteric fistula and one graft limb occlusion), for an early graft-related complication rate of 12% (n = 4). Of the 31 discharged patients, 13 (42%) had died after a median of 47 months (range, 2-97 months). The median follow-up for the 18 remaining patients was 96 months (range, 10-146 months). The estimated survival at 1, 3, and 5 years was 88%, 81%, and 66%, respectively. Nine patients (29%) had experienced at least one of the following graft-related events during follow-up, including graft stenosis requiring intervention in five (16%), graft occlusion in four (13%), pseudoaneurysm in three (10%), and reinfection in two patients (6%). The estimated freedom from any first graft-related event at 1, 3, and 5 years was 78%, 71%, and 62%, respectively. The estimated primary patency and primary assisted patency at 1 and 3 years was 87% and 79%, and 90% and 83%, respectively.

CONCLUSIONS

In situ aortoiliac reconstruction with cryopreserved allografts to treat VGI was associated with relevant perioperative graft-related complications. Although the reinfection rate was acceptable, other graft-related complications were frequent in the long term, in particular, graft occlusion and stenosis.

Novel prefabricated bovine pericardial grafts as alternate conduit for septic aortoiliac reconstruction

OBJECTIVE

Infection of prosthetic aortic grafts represents a serious complication with high morbidity and mortality. Replacement with autologous material is recommended; however, in its absence, biological material should be favored. In the present retrospective cohort study, we evaluated the short- and midterm results with the use of commercially available prefabricated bovine pericardium grafts (BPGs) used for the management of aortic graft infection or aortic reconstructive surgery in the presence of systemic infection.

METHODS

We performed a retrospective analysis of patients in whom BPGs had been used for aortic reconstruction at two vascular centers. Prefabricated vascular pericardium grafts were preferred over other biological reconstruction techniques for selected cases. Comorbidities, procedure-related details, perioperative morbidity, clinical outcomes, and mortality were analyzed.

RESULTS

From 2014 to 2019, 21 patients had received BPGs at two Austrian vascular centers. Their median age was 63 years (interquartile range [IQR], 55-71 years), the patients were predominantly male (76%), and the median body mass index was 25.3 kg/m² (IQR, 21.7-27.3 kg/m²). The major comorbidities included arterial hypertension, peripheral artery disease, smoking, and chronic pulmonary disease. The indications for surgery were vascular graft or endograft infection in 62% and aortic reconstruction in the presence of systemic infection in 38%. Three patients (14%) had aortoenteric fistulas. Surgery was technically successful in all cases. The median follow-up was 21.6 months (IQR, 6.0-34.6 months). The 30-day mortality was 9.5%. The 1- and 2-year overall survival was 84% and 75%, respectively. Of the 21 patients, 89% had remained free of recurrent infection. One of the two reinfections had resolved after treatment of the underlying focus. At 2 years, the primary and assisted primary patency rates were 86% and 94%, respectively. No limbs were lost during follow-up.

CONCLUSIONS

Prefabricated BPGs represent a promising alternative for the management of aortic graft infections and aortoiliac reconstruction in the presence of systemic infection.

Endovascular repair of a cadaveric vascular allograft nonanastomotic pseudoaneurysm

Patients who have undergone revascularization with a cryopreserved cadaveric arterial allograft (CCAA) require lifelong surveillance because of the risk of allograft failure. The reported long-term complications of these grafts include thrombosis, anastomotic pseudoaneurysm, and graft disruption. We have described a case in which a CCAA developed a nonanastomotic pseudoaneurysm at the site of a previously ligated branch vessel and was repaired using a covered stent graft. This case demonstrates that spontaneous rupture of CCAA branches is a late complication that can occur when using these grafts and that endovascular methods are an option for repair.

Cryopreserved Venous Allografts in Supra-inguinal Reconstructions: A Single Centre Experience

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 = 12 [52%]), mycotic aneurysms (n = 5 [22%]), femorofemoral prosthetic infections (n = 3 [13%]), anastomotic pseudo-aneurysms (n = 2 [9%]), and aortic thrombosis with intestinal spillage (n = 1 [4%]). In hospital and 90 day mortality were 9% (n = 2); overall treatment related mortality during the median follow up of 15 months was 13% (n = 3). During the follow up, two allografts were re-operated on owing to anastomotic dilatation and one because of re-infection, resulting in a re-intervention rate of 13% (n = 3). None of the grafts was lost and there were no amputations. At the end of follow up 17 patients (74%) were alive. Kaplan-Meier estimation for survival was 76% (95% confidence interval [CI] 57%-95%) at one year and 70% (95% CI 49%-91%) 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.

Editor's Choice - Cryopreserved Allografts for Arterial Reconstruction after Aorto-Iliac Infection: A Systematic Review and Meta-Analysis

OBJECTIVE

Native and aortic graft infections are rare, but they represent one of the most life threatening complications of vascular surgery. Several materials and surgical approaches have been developed so far. Among them, cryopreserved allografts have been proposed as a treatment option. A systematic review and meta-analysis was conducted to investigate the role of cryopreserved allografts for arterial reconstruction after aorto-iliac infection.

METHODS

The current meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Patient baseline characteristics were investigated, along with 30 outcomes after use of cryopreserved arterial allografts for reconstruction after aorto-iliac infection. Pooled proportions with 95% CIs of outcome rates were calculated.

RESULTS

A total of 31 studies, including 1,377 patients, finally participated in the meta-analysis. Among the early outcomes, 30 day mortality was 14.91% (95% CI 11.78-18.31). Peri-anastomotic rupture/allograft disruption rate was 5.90% (95% CI 2.77-9.88), while pooled aneurysmal degeneration/allograft dilatation was 4.99% (95% CI 1.60-9.68). A pooled rate of 3.11% (95% CI 1.60-4.98) was estimated for pseudoaneurysm formation after the use of cryopreserved arterial allografts, while the allograft thrombotic/stenotic complication rate and peri-anastomotic infection were 12.19% (95% CI 7.90-17.15) and 3.32% (95% CI 1.90-5.03), respectively. Mortality during follow up was 19.24% (95% CI 11.97-27.58), while allograft related mortality during follow up was 3.58% (95% CI 1.56-6.15). A pooled allograft related re-operation rate was estimated at 24.87% (95% CI 17.89-32.51).

CONCLUSIONS

The use of cryopreserved allograft seems to be a safe and durable option with acceptable outcomes for treatment of aorto-iliac infection.

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.

Ten Year Experience of Using Cryopreserved Arterial Allografts for Distal Bypass in Critical Limb Ischaemia

OBJECTIVE/BACKGROUND

In critical limb ischaemia (CLI), current guidelines recommend revascularisation whenever possible, preferentially through endovascular means. However, in the case of long occlusions or failed endovascular attempts, distal bypasses still have a place. Single segment great saphenous vein (GSV), which provides the best conduit, is often not available and currently there is no consensus about the best alternative graft.

METHODS

From January 2006 to December 2015, 42 cryopreserved arterial allografts were used for a distal bypass. Autologous GSVs or alternative autologous conduits were unavailable for all patients. The patients were observed for survival, limb salvage, and allograft patency. The results were analysed with Kaplan-Meier graphs.

RESULTS

Estimates of secondary patency at one, two and five years were 81%, 73%, and 57%, respectively. Estimates of primary patency rates at one, two and five years were 60%, 56%, and 26%, respectively. Estimates of limb salvage rates at one, two and five years were 89%, 89%, and 82%, respectively. Estimates of survival rates at one, two and five years were 92%, 76% and 34%, respectively. At 30 days, major amputations and major adverse cardiac events were one and zero, respectively. Six major amputations occurred during the long-term follow up.

CONCLUSION

Despite a low primary patency rate at two years, the secondary patency of arterial allografts is acceptable for distal bypasses. This suggests that cryopreserved arterial allografts are a suitable alternative for limb saving distal bypasses in the absence of venous conduits, improving limb salvage rates and, possibly, quality of life.

Obturator Bypass with Bovine Carotid Artery Graft: A Novel Twist to a Traditional Technique

When managing an infected groin, though rarely performed, a transobturator bypass remains an important alternative in the armament of a vascular surgeon. Autologous vein and synthetic PTFE are known conduit options for obturator bypasses, although the advantage of utilizing an autologous biological conduit when dealing with infection may not be an option for every patient. On literature review, bovine carotid grafts have been used in infrainguinal revascularizations with comparable results to autologous vein; however, no cases can be found for its use in obturator bypass thus far.

Peripheral artery reconstructions using cryopreserved arterial allografts in infected fields

OBJECTIVE

Cryopreserved human arterial allografts are a recognized acceptable alternative for vascular reconstruction when other traditional conduits are either unavailable or contraindicated. We reviewed our experience using cryopreserved arterial allografts for peripheral artery reconstructions in contaminated and infected surgical fields.

METHODS

A single-center, retrospective review was conducted of 57 patients who underwent a peripheral vascular reconstruction using a cryopreserved arterial allograft from January 2002 through July 2017. Indications for repair included removal of infected prosthetic bypass (n = 29), revascularizations in contaminated fields (n = 11), primary arterial repair in the setting of infection (n = 10), and infected vascular closure devices (n = 7). Aorta-based repairs were excluded. Demographics, index procedural details, postoperative complications, and conduit patency were analyzed. Primary end points included conduit-related mortality and graft failure as measured by reinfection, hemorrhage, or aneurysmal degeneration. Mean follow-up for the study is 27.8 months (range, 2-125 months).

RESULTS

A total of 57 peripheral vascular reconstructions using cryopreserved arterial allografts were performed during the 15-year period. Among the 22 women and 35 men treated, the mean age was 61 years. The vascular beds involved included iliofemoral (n = 39), femoropopliteal or femoral-distal (n = 10), axillosubclavian or brachial (n = 2), mesenteric (n = 3), and carotid (n = 3) arteries. Adjunctive muscle flap coverage of the allograft conduit was performed in the majority of cases (61%; n = 35). The 30-day mortality was 9%; one death was directly related to conduit insertion. The 30-day conduit-related complication rate was 14% and included hemorrhage from the graft requiring return to the operating room (n = 4) and graft infection (n = 4). The late conduit-related complication rate was 15.8% and included graft infection (n = 1), graft thrombosis (n = 3), major amputation resulting from conduit failure (n = 1), pseudoaneurysm degeneration requiring repair (n = 2), graft hemorrhage (n = 1), and symptomatic graft stenosis (n = 1).

CONCLUSIONS

A cryopreserved arterial allograft is a useful alternative conduit for peripheral vascular reconstruction in infected or contaminated surgical fields when other autologous or prosthetic conduits are either unavailable or contraindicated. In the immediate postoperative period, these repairs demonstrate acceptable resistance to graft failure and reinfection, particularly in conjunction with adjunctive rotational muscle flap coverage. Late conduit-related complications appear to be infrequent.

Vascular Graft Infections: An update

Vascular graft infection is a devastating complication of vascular reconstructive surgery. The infection can occur early in the postoperative period and is largely due to intraoperative contamination or by contiguous extension from a nearby infection. It can also occur years after implantation. Staphylococci remain the most common organisms and biofilm production makes eradication difficult. Factors commonly reported to predispose to vascular graft infection are periodontal disease, nasal colonization with Staphylococcus aureus, bacteremia, certain graft characteristics, diabetes mellitus, postoperative hyperglycemia, location of the incision, wound infection, and emergency procedure. Management consists of antibiotic and surgical therapy. Preventive methods are described.