Treatment of infectious aortic disease with bovine pericardial tube grafts

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.

Physician Made Bovine Pericardial Tube Grafts in Aortic Infection: A European Multicentre Study

OBJECTIVE

This study examines outcome and durability of physician made bovine pericardial tube grafts in aortic infections in all anatomical locations.

METHODS

This was a retrospective and prospective international multicentre study. Peri-operative and long term outcomes of patients undergoing in situ aortic reconstruction for native or graft infections with physician made bovine pericardial tube grafts between January 2008 and December 2020 in four European tertiary referral centres were analysed. The primary endpoint was recurrent aortic infection. Secondary endpoints were persistent infection, aortic re-operation for infection, graft related complications, and death.

RESULTS

One hundred and sixty eight patients (77% male, mean age 67 ± 11 years) were identified: 38 (23%) with native and 130 (77%) with aortic graft infection. The thirty day mortality rate was 15% (n = 26) overall, 11% (n = 4), and 17% (n = 22) for native and aortic graft infections, respectively (p = .45). Median follow up was 26 months (interquartile range [IQR] 10, 51). Estimated survival at one, two, three, and five years was 64%, 60%, 57%, and 50%, and significantly better for native (81%, 77%, 77%, and 69%) than for graft infections (58%, 55%, 51%, and 44%; p = .011). Nine patients (5.3%) had persistent infection and 10 patients (6%) had aortic re-infection after a median of 10 months (IQR 5, 22), resulting in an estimated freedom from re-infection at one, two, three, and five years of 94%, 92%, 90%, and 86%. Estimated freedom from graft complications at one, two, three, and five years was 91%, 89%, 87%, and 87%.

CONCLUSION

This multicentre study demonstrates low re-infection rates when using physician made bovine pericardial tube grafts, comparable to those of other biological grafts. The rate of graft complications, mainly anastomotic aneurysms and stenoses, was low, while graft degeneration was absent. Physician made bovine pericardial tube grafts are an excellent tool for in situ reconstruction in the setting of native aortic infection or aortic graft infection.

Aortic root pseudoaneurysm: a case report and literature review

Pseudoaneurysms of the aortic root are rare. A case of prosthetic aortic valve infection progressing from a confined intramural abscess to a ruptured abscess communicating with the aorta and forming a large pseudoaneurysm is described. Additionally, data from all cases and case series, published between 2000 and 2021, was analyzed. A PUBMED search for the keywords "aortic root mycotic aneurysm," "aortic root abscess AND infective endocarditis," and "aortic root mycotic aneurysm AND infective endocarditis" yielded 152 publications (with 157 cases described): Aortic pseudoaneurysm is more common in males (80.9%, n = 127). Mean age is 51 years (4 months-84 years). The most common symptom is fever (68.5%, n = 102). Mean time until diagnosis is 27.2 days. Embolic complications are present in 17.8% (n = 28) at diagnosis. Most cases are due to valvular infections (n = 72 cases, 45.9%). Prior cardiac surgery is documented in 49.0% (n = 77). The mean time interval for developing aortic root abscess following heart surgery is 32.2 months. 22.3% (n = 35) are immunocompromised. Aetiological agents were Staphylococcus sp. (34.1%, n = 47) and Streptococcus sp. (23.2%, n = 32). Mean antimicrobial therapy lasts 58.5 days. Outcome with surgery is superior to medical treatment: overall inpatient mortality 18.5% (n = 27); with surgery 12.2% (n = 15 out of 123 patients), with only medical management 47.8% (n = 11 out of 23 patients). In conclusion, aortic root pseudoaneurysm occurs most commonly in middle-aged male patients. History of prior aortic procedures is commonly present. Correct diagnosis hinges on detailed history, transoesophageal echocardiography, and computed tomography (CT) aorta. Surgery is the preferred therapeutic option.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-023-01580-x.

Surgical treatment of thoracic aortic pseudoaneurysm caused by Brucella melitensis

Thoracic aortic pseudoaneurysm caused by Brucella melitensis is extremely rare with extremely few cases reported to date. Herein, we present the case of a 65 year-old man with a huge pseudoaneurysm of the proximal descending thoracic aorta, involving the left subclavian artery and distal arch. Surgery was performed to replace the proximal descending aorta with a self-made bovine pericardial duct and the left subclavian artery with a 10 mm artificial vessel under deep hypothermic circulatory arrest; the patient recovered uneventfully. However, continued follow-up is required for long-term results.

Treatment of infected hybrid arch prosthesis with self-assembled bovine elephant trunk grafts

Graft infections are associated with severe morbidity and mortality. The widespread use of the frozen elephant technique increases the incidence of complex aortic patients to suffer from graft infections. Surgery of these patients is challenging. Removal of the stent graft portion of the frozen elephant technique prosthesis via sternotomy carries the risk of irreparable damage to the descending aorta. There is currently no single-stage surgical strategy that allows for the removal of all infected material apart from a hemi-clamshell approach. This approach is technically demanding and associated with significant morbidity and mortality. This results in conservative treatment in a substantial number of patients. Pericardial tube grafts have shown to be an excellent option in treating graft infections in various aortic segments with promising results concerning freedom of re-infection and survival. We report a single-stage, trans-sternal approach to remove all infected materials and simultaneously treat the descending aorta to prevent aortic catastrophe in 2 consecutive cases.

Early and mid-term outcomes of thoracic endovascular aortic repair to treat aortic rupture in patients with aneurysms, dissections and trauma

OBJECTIVES

The aim of this study was to analyse outcomes of thoracic endovascular aortic repair to treat aortic rupture.

METHODS

Patient and outcome characteristics of all emergent endovascular treatments for thoracic aortic rupture between January 2009 and December 2019 were analysed.

RESULTS

Thoracic aortic rupture occurred in patients with aortic aneurysms (n = 42, 49%), aortic dissection (n = 13, 16%) or after trauma (n = 30, 35%). Preoperative cerebrospinal fluid drainage was placed in 9 patients (11%) and 18 patients (21%) underwent perioperative supra-aortic transposition. The proximal landing zones were: zone 1 (n = 1, 1%), zone 2 (n = 23, 27%), zone 3 (n = 52, 61%) and zone 4 (n = 9, 11%). Temporary spinal cord injury occurred in 1 patient (1%), permanent spinal cord injury in 7 patients (8%). Two patients (2%) experienced a postoperative stroke. Seventeen patients (20%) expired in-hospital. Aortic dissection (odds ratio: 16.246, p = 0.001), aneurysm (odds ratio: 9.090, P = 0.003) and preoperative shock (odds ratio: 4.646, P < 0.001) were predictive for mortality. Eighteen patients (21%) required a stent-graft-related aortic reintervention for symptomatic supra-aortic malperfusion (n = 3, 4%), endoleaks (n = 6, 7%), a second aortic rupture (n = 4, 5%), retrograde type A aortic dissection (n = 2, 2%), aortic-oesophageal fistulation (n = 2, 2%) and stent-graft kinking (n = 1, 1%).

CONCLUSIONS

Thoracic endovascular aortic repair in patients with aortic rupture has become a valuable treatment modality to stabilize patients. However, a significant risk of postoperative morbidity and mortality remains, particularly in patients with aortic dissections, aneurysms or shock. Patients require thorough follow-up ideally in an aortic clinic with a staff having the entire spectrum of cardiovascular and thoracic surgical expertise.

Downstream thoracic endovascular aortic repair following the frozen elephant trunk procedure

The frozen elephant trunk technique has become a well-established treatment option for patients presenting all thoracic aortic pathologies including acute and chronic dissection, aortic aneurysms and even penetrating aortic ulcers involving the aortic arch and descending aorta. Nevertheless, there is a significant incidence of and risk for distal aortic reinterventions after the frozen elephant trunk. Indications mainly include a planned staged approach, diameter progression of downstream aortic segments and the development of distal stent-graft induced new entries (dSINEs). Endovascular stent-graft extension through conventional thoracic endovascular aortic repair (TEVAR) is a relatively simple and safe method to address any pathologies in the remaining descending thoracic aorta up to the level of the coeliac trunk. In fact, the frozen elephant trunk stent-graft provides an ideal proximal landing zone for any endovascular stent-graft extension. Postoperative outcomes are very promising with very low reported in-hospital mortality and morbidity. In case this 2-staged-approach fails to stabilize the remaining aorta, a 3-step procedure, namely open thoracoabdominal aortic replacement, is simplified because the anastomosis site has moved distally. Follow-up of all patients, following frozen elephant trunk implantation or distal stent-graft extension, is mandatory, ideally in an outpatient clinic dedicated to the aorta in order to identify disease progression or to detect any complications as soon as possible.