Axillofemoral bypass in the management of infected aortic bifurcation "dacron" graft

Priority of revascularization in patients with graft enteric fistulas, infected arteries, or infected arterial prostheses

Patients with arterial infections, infected arterial prostheses, or graft enteric erosions or fistulas have high amputation and mortality rates after treatment. An unresolved therapeutic question is whether remote ("extra-anatomic") bypass should precede or follow removal of the infected artery or prosthesis. None of the ten patients reported here who had a remote bypass inserted first developed distal limb ischemia or infection of the remote bypass. Literature review of patients with aortic prosthetic infections revealed a mortality of 71% (10/14) if infected graft removal preceded remote bypass and 26% (6/23) if remote bypass was first. Patients with graft enteric erosions or fistulas had a mortality of 53% (40/75) if graft removal was first and 17% (5/29) if remote bypass was first. Subsequent infection of the remote bypass was rare. Therefore, when possible, remote bypass with a prosthetic graft should precede removal of an infected artery, an infected arterial prosthesis, a graft enteric erosion, or a graft enteric fistula.

Axillofemoral arterial bypass grafts

The results of 24 axillofemoral arterial bypass grafts performed over a five-year period are presented. This extraanatomical technique of arterial reconstruction is valuable following removal of an infected aortic Dacron graft and for limb salvage or severe intermittent claudication in selected poor-risk patients with aortoiliac occlusive disease. There were few early patency rate was excellent, but the long-term success of the operation is uncertain.

The management of infected abdominal aortic grafts and graft-enteric fistulas

Seven cases of infected aortic grafts or aorto-enteric fistulas following resection of an abdominal aortic aneurysm are reviewed. All cases were treated with axillo-femoral bypass and graft removal. Patients had recurrent fever, chills, and abdominal pain (5 patients), or massive gastrointestinal hemorrhage (2 patients). The two patients with massive gastrointestinal hemorrhage died. Three of the 5 long-term survivors had a recurrence of the retroperitoneal abscess after graft removal; one of these died. One axillo-femoral bypass graft required early thrombectomy. There have been no subsequent problems with any of the grafts in the 2.5 to 4 year followup period. Axillo-femoral bypass immediately before graft removal is the treatment of choice for infected or fistulous aortic grafts. Any delay in graft removal after the onset of symptoms should be avoided.

Abdominal aneurysm with aortoduodenal fistula

Two patients having the abdominal aneurysm with aortoduodenal fistula were treated surgically, but graft infection occurred. One patient died about 6 months after and the other about one year after the operation due to massive hemorrhage from the postoperative aortointestinal fistula. The difficulties in the treatment of the aortoduodenal fistula were discussed.