Endovascular repair of aortic allograft aneurysmal degeneration: a case report

Endovascular Treatment of Aneurysmal Deterioration in Peripheral Arterial Allografts

Purpose:

To report endovascular treatment of 2 patients with aneurysmal deterioration of peripheral arterial allografts.

Case Report:

Two men (65 and 64 years old) who had undergone an arterial allograft reconstruction for infection of prosthetic infrapopliteal bypass grafts 5 and 7 years ago, respectively, were diagnosed with asymptomatic aneurysmal deterioration of the allografts. Stent-graft repair was successful in both cases, completely excluding the aneurysms. At ≥1 year, continued aneurysm exclusion was confirmed by duplex scan, with no evidence of endoleak, migration, or stenosis.

Conclusion:

Endovascular treatment may be a useful therapeutic option when treating patients with late peripheral allograft deterioration.

Arterial reconstruction for atypical mycotic aneurysms

Our case involves a 67-year-old man with a  post lung transplantation status for idiopathic pulmonary fibrosis, who was initially referred to our institution for treatment of left hip septic arthritis due to Pseudallescheria boydii infection. One month following total hip arthroplasty, he noticed left upper thigh swelling with duplex imaging consistent with a 7-cm mid-superficial femoral artery aneurysm with popliteal vein compression and associated deep venous thrombosis. During operative resection, exploration of his contralateral saphenous vein showed inadequate conduit for use. Therefore, we proceeded with proximal and distal clamp control with intraoperative arterial shunting followed by cryoarterial reconstruction after complete aneurysm sac resection and debridement. Intraoperative arterial wall cultures remained negative for bacterial pathogens; however, final operative fungal cultures once again grew Pseudallescheria boydii. Our case highlights the complexity of adequate source control with effective arterial reconstruction in these immunosuppressed patient populations, particularly with fungal organisms that historically have poor therapeutic response to medical therapy alone.

Infrarenal iterative aortic surgery: early and late morbi-mortality observed in 61 patients

The aim of this study was to analyze the early and late results of iterative aortic surgery after bypass of infrarenal aorta. Results from Clermont-Ferrand and Saint-Etienne hospitals have been collected. Between January 1993 and December 2001, 61 patients (59 men and two women, mean age 65 years) underwent a partial or complete second aortic reconstruction through a direct approach. Three different indications that required redo surgery were detected. Twenty-three patients presented with an infection (37%), 17 with an occlusive pathology (28%), and 21 with an aneurysm (34%). Medical or endoluminal treatment could no longer be considered. Mean period of time for redo surgery was 101 months (range 1-294). Eighteen of the procedures were emergency surgeries. A polyester prosthesis was used in 45 cases, an arterial allograft in 15 cases, and autogenous venous material in one case. In 22 cases (36%) a visceral, renal, or infracrural revascularization was associated. Four patients died (6.5%): three with an infection and one with an occlusive pathology. Global morbidity rate was 64%. Twelve vascular surgical complications (19%) required redo surgery: seven limb ischemia, three hemorrhage, and two colic ischemia. The preoperative factors generating severe complications were a septic context, renal insufficiency, and American Society of Anesthesiologists grade 3 or 4. Follow-up concerned the 57 surviving patients with a 43-month mean period of time (range 4-105). Actuarial survival rate was 80.7% at 3 years and could be compared to that observed after infrarenal aortic first surgery. Primary and secondary global patency rates were, respectively, 66.4 +/- 6.7% and 94.6 +/- 3% at 3 years with no major amputation. In our series including 37% of septic patients and nearly 30% of patients operated on in emergency, aortic iterative surgery led to mortality and morbidity rates twice and four times as important as those resulting from infrarenal aortic initial surgery, respectively. In the long term, patient survival and limb salvage rates were quite similar to those obtained with de novo surgery.

Allograft replacement for infrarenal aortic graft infection: early and late results in 179 patients

OBJECTIVES

We evaluated early and late results of allograft replacement to treat infrarenal aortic graft infection in a large number of patients and compared the results in patients who received fresh allografts versus patients who received cryopreserved allografts.

METHODS

From 1988 to 2002 we operated on 179 consecutive patients (mean age, 64.6 +/- 9.0 years; 88.8% men). One hundred twenty-five patients (69.8%) had primary graft infections, and 54 patients (30.2%) had secondary aortoenteric fistulas (AEFs). Fresh allografts were used in 111 patients (62.0%) until 1996, and cryopreserved allografts were used in 68 patients (38.0%) thereafter.

RESULTS

Early postoperative mortality was 20.1% (36 patients), including four (2.2%) allograft-related deaths from rupture of the allograft (recurrent AEF, n = 3), all in patients with fresh allografts. Thirty-two deaths were not allograft related. Significant risk factors for early mortality were septic shock (P <.001), presence of AEF (P =.04), emergency operation (P =.003), emergency allograft replacement (P =.0075), surgical complication (P =.003) or medical complication (P <.0001), and need for repeat operation (P =.04). There were five (2.8%) nonlethal allograft complications (rupture, n = 2; thromboses, which were successfully treated at repeat operation, n = 2; and amputation, n = 1), all in patients with fresh allografts. Four patients (2.2%) were lost to follow-up. Mean follow-up was 46.0 +/- 42.1 months (range, 1-148 months). Late mortality was 25.9% (37 patients). There were three (2.1%) allograft-related late deaths from rupture of the allograft, at 9, 10, and 27 months, respectively, all in patients with fresh allografts. Actuarial survival was 73.2% +/- 6.8% at 1 year, 55.0% +/- 8.8% at 5 years, and 49.4% +/- 9.6% at 7 years. Late nonlethal aortic events occurred in 10 patients (7.2%; occlusion, n = 4; dilatation < 4 cm, n = 5; aneurysm, n = 1), at a mean of 28.3 +/- 28.2 months, all but two in patients with fresh allografts. The only significant risk factor for late aortic events was use of an allograft obtained from the descending thoracic aorta (P =.03). Actuarial freedom from late aortic events was 96.6% +/- 3.4% at 1 year, 89.3% +/- 6.6% at 3 years, and 89.3% +/- 6.6% at 5 years. There were 63 late, mostly occlusive, iliofemoral events, which occurred at a mean of 34.9 +/- 33.7 months in 38 patients (26.6%), 28 of whom (73.7%) had received fresh allografts. The only significant risk factor for late iliofemoral events was use of fresh allografts versus cryopreserved allografts (P =.03). Actuarial freedom from late iliofemoral events was 84.6% +/- 7.0% at 1 year, 72.5% +/- 9.0% at 3 years, and 66.4% +/- 10.2% at 5 years.

CONCLUSIONS

Early and long-term results of allograft replacement are at least similar to those of other methods to manage infrarenal aortic graft infections. Rare specific complications include early or late allograft rupture and late aortic dilatation. The more frequent late iliofemoral complications may be easily managed through the groin. These complications are significantly reduced by using cryopreserved allografts rather than fresh allografts and by not using allografts obtained from the descending thoracic aorta.