In situ autogenous reconstruction of the thoracoabdominal aorta and branches for treatment of an infected thoracoabdominal aortobifemoral bypass graft

Autologous deep vein reconstruction of infected thoracoabdominal aortic patch graft

Graft infection remains a serious complication of prosthetic aortic repair. Infection of thoracoabdominal aortic prosthetic grafts, in particular, is a significant clinical challenge and is associated with high mortality. We report successful in situ reconstruction of an infected thoracoabdominal aortic prosthetic patch graft with autogenous superficial femoral vein. To our knowledge, this is the first such case described in the North American and English language surgical literature. At 24-month follow-up the patient remains well, with no evidence of sepsis or graft complication at clinical and radiologic assessment.

Prosthetic graft infection after descending thoracic/ thoracoabdominal aortic aneurysmectomy: management with in situ arterial allografts

PURPOSE

Prosthetic graft infection is an uncommon but life-threatening complication of descending thoracic/thoracoabdominal aortic aneurysmectomy. The purpose of this study was to assess the value of in situ arterial allografts in the management of this complication.

METHODS

From 1992 to 2000 we treated 11 consecutive patients with prosthetic graft infection after descending thoracic/thoracoabdominal aortic aneurysmectomy by replacing the prosthetic graft with an in situ arterial allograft. There were 10 men and one woman with a mean age of 50.8 years (range, 32-73 years). The primary aortic disease was degenerative aneurysm in 6 patients, chronic type B dissection in 2 patients, inflammatory aneurysm in 1 patient, Marfan's disease in 1 patient, and Behçet's disease in 1 patient. Replacement involved only the descending thoracic aorta in three patients and more or less extensive segments of the thoracoabdominal aorta in eight patients. Signs of severe infection were present in all patients, and false anastomotic aneurysms were noted in six patients. Aortoenteric fistula occurred in three patients and aortobronchial fistula in two patients. The causative organisms were identified in nine patients. The mean interval between the primary surgery and reoperation was 33.4 +/- 27.5 months. Reoperation was performed under emergency conditions because of hemorrhage in three patients. Cardiopulmonary bypass with deep hypothermic circulatory arrest was used in seven patients. Allograft replacement of the aorta was associated with reimplantation of intercostal and/or visceral arteries in all patients.

RESULTS

One patient died intraoperatively of heart failure during emergency surgery. Two patients died of persistent infection during the postoperative period at 19 and 58 days. Mean follow-up was 34 +/- 19 months. One patient died during the late follow-up period after surgery of the infrarenal aorta. Another patient underwent surgery for stenoses of one branch of a bifurcated allograft and a renal bypass graft to a solitary kidney.

CONCLUSIONS

The use of in situ arterial allografts is a significant advance in the management of prosthetic graft infection after descending thoracic/thoracoabdominal aortic aneurysmectomy provided that reoperation is performed early.