Salvage of Prosthetic Vascular Graft Infection in the Distal Thigh Using Free Latissimus Dorsi Musculocutaneous Flap: A Case Report

BACKGROUND

Prosthetic vascular graft infection (PVGI) in the distal thigh is a rare wound; thus, little is known about which muscle flaps are the most useful and cause less lower extremity morbidity in such cases. Moreover, very few reliable muscle flaps are available around the distal thigh.

CASE REPORT

We report the case of a 72-year-old woman suffering from a distal thigh wound with PVGI. The graft was successfully preserved after coverage with a free latissimus dorsi musculocutaneous (LDM) flap.

CONCLUSIONS

The free LDM flap procedure is more challenging than local muscle flaps; however, a free LDM flap can be a feasible option for a distal thigh wound with PVGI with the advantage of the maintenance of walking capability by preserving the lower-limb muscles.

Polyester Vascular Graft Material and Risk for Intracavitary Thoracic Vascular Graft Infection1

Prosthetic vascular graft infections of the thoracic aorta are rare but can be fatal. Our comparison of collagen- and gelatin-coated grafts showed that collagen-coated grafts were associated with increased biofilm formation and bacterial adherence in vitro and with higher rates of perioperative vascular graft infections in vivo.

Perigraft abscess after DeBakey type-1 aortic dissection: a case report

Background

Perigraft abscess is a rare condition which constitutes a small proportion of aortic graft infection (AGI). Early diagnosis is very important for timely intervention and improving the survival rate of patients because of its significant morbidity and mortality.

Case presentation

A 24-year-old young male patient with a history of complicated total arch replacement using elephant trunk technique for acute DeBakey type-1 aortic dissection 6 months before visited our hospital with the chief complaint of persistent fever. Antibiotic treatment in local hospital was ineffective. Echocardiography showed liquid dark area around the aortic graft, and a computerized tomography angiography (CTA) was done for further evaluation of periaortic fluid collection which showed findings to suggest perigraft abscess. The patient underwent surgical debridement of the abscess and was found to have an abscess around the aortic graft which was drained followed by antibiotic treatment. The patient was discharged to his local hospital and recovered well at 2 month follow-up appointment.

Conclusion

This is a very rare case of aortic abscess around the graft that could successfully be managed by graft-conserving surgery, and it emphasizes the significance of early diagnosis of perigraft abscess in patients with aortic dissection surgery.

Retrospective Study Comparing WBC scan and 18F-FDG PET/CT in Patients with Suspected Prosthetic Vascular Graft Infection

OBJECTIVES

Prosthetic vascular graft infections (PVGIs) are associated with high mortality rates. To improve treatment outcome, an early and definite diagnosis is critical, and current diagnostic criteria are often insufficient. The accuracy of 2-deoxy-2-[fluorine-18]-fluoro-d-glucose positron emission tomography integrated with computed tomography (¹⁸F-FDG PET/CT) and white blood cell (WBC) scan for the diagnosis of PVGI were compared.

METHODS

A retrospective single centre study was conducted on patients undergoing WBC scan and ¹⁸F-FDG PET/CT for a suspected PVGI between April 2013 and June 2016 at the Bordeaux University Hospital, France. The diagnostic value of both imaging tests was assessed for all grafts, using receiver operating characteristic (ROC) curve analysis. Images were independently interpreted by two nuclear medicine physicians blinded to the patients' clinical and other imaging data.

RESULTS

Thirty-nine patients were included, of whom 15 had PVGI. Antibiotic treatment was started before nuclear imaging for 16 patients, including nine patients with a PVGI. The 96 grafts of these patients were analysed, and 19 were infected. The diagnostic value of the WBC scan was significantly higher than ¹⁸F-FDG PET/CT (ROC AUC = 0.902, 95% CI 0.824-0.980, and 0.759, CI 95% (0.659-0.858), respectively, p = .0071). Interobserver agreement was good for ¹⁸F-FDG PET/CT and excellent for WBC scan (kappa value of 0.76, 95% CI 0.62-0.9, and 0.97, 95% CI 0.92-1, respectively). Only one patient had a false negative ¹⁸F-FDG PET/CT result under antibiotic therapy.

CONCLUSION

The WBC scan has a better diagnostic value than ¹⁸F-FDG PET/CT for PVGI diagnosis.

Prosthetic vascular graft infection and prosthetic joint infection caused by Pseudomonas stutzeri

Pseudomonas stutzeri is infrequently isolated from clinical specimens, and if isolated, more likely represents colonization or contamination rather than infection. Despite this, there are dozens of case reports which describe clinically significant P. stutzeri infections at variable sites. A 69-year-old man had a P. stutzeri infection of a prosthetic vascular graft infection, which he received in Panama City. He was successfully treated with a single antipseudomonal agent for 6 weeks and the removal of the infected vascular graft. A 70-year-old man had a P. stutzeri infection of a prosthetic joint, which was successfully treated with a single anti-pseudomonal agent for 6 weeks. There is only one other documented case of a prosthetic vascular graft infection secondary to P. stutzeri. There are 5 documented cases of P. stutzeri prosthetic joint infections. The previous cases were treated with antibiotics and variably, source control with the removal of prosthetic material. Most cases of P. stutzeri infection are due to exposure in health care settings. Immunocompromised states such as HIV or hematological and solid tumor malignancies are risk factors for P. stutzeri infection. Infections caused by P. stutzeri are far less frequent and less fatal than those caused by P. aeruginosa. The etiology of a P. stutzeri infection could be exposure to soil and water, but also contaminated material in the health care setting or an immunocompromised state. Iatrogenic infections that are secondary to health care tourism are a potential cause of fever in the returned traveler.

Prosthetic vascular graft infection through a median sternotomy: a multicentre review †

OBJECTIVES

The aim of this study is to analyse the treatment outcomes of thoracic prosthetic graft infection.

METHODS

A retrospective chart review was conducted at six hospitals and included the records of 68 patients treated for postoperative prosthetic vascular graft infection (mean age: 62.3 ± 15.1, male 51) from January 2000 to December 2013. The number of patients and the locations of the treated infections were as follows: 13 for aortic root, 16 for ascending aorta, 35 for aortic arch and 4 for aortic root to arch. In-hospital infection occurred in 43 patients and after discharge in 25.

RESULTS

The mean follow-up time was 2.0 ± 2.3 years. The follow-up rate was 94.1%. The most commonly isolated micro-organism was Staphylococcus aureus (72.1%). Rereplacement of infectious graft was performed in 18 patients (Dacron graft in 12, homograft in 4 and rifampicin-bonded Dacron graft in 2). The overall hospital mortality rate was 35.3% (24/68). The mortality rate among the patients with graft rereplacement was 33.3% (6/18), with pedicled muscle flaps or pedicled omental flaps to cover the graft 25.9% (7/27), with irrigation 55.0% (11/20) and on antibiotic therapy only 0% (0/3). Our multivariate analysis demonstrated that the risk factors of hospital death increased in the absence of pedicled flaps (muscle or omentum) to cover the graft (P = 0.001), age over 55 (P = 0.003), time from onset of initial operation <1 week (P = 0.031) and period before 2008 (P = 0.001). The overall 1-year survival rate was 58.6%.

CONCLUSIONS

The treatment outcomes of thoracic prosthetic vascular graft infection have not been satisfactory. However, the use of pedicled muscle or omental flaps to cover the graft could improve the outcomes.

Tolerability of High Doses of Daptomycin in the Treatment of Prosthetic Vascular Graft Infection: A Retrospective Study

INTRODUCTION

In treatment of prosthetic vascular graft infection (PVGI), appropriate antimicrobial treatment is crucial for controlling the septic process and preventing re-infection of the new graft. Glycopeptides are the mainstay of treatment for device-related infections by methicillin-resistant Staphylococcus aureus strains, but with some limitations, especially concerning vancomycin-intermediate and glycopeptide-intermediate S. aureus. We report our experience using a high dose of daptomycin (DAP) for treatment of PVGI.

METHODS

We reviewed medical reports of 26 patients treated with high doses of DAP (>8 mg/kg) and beta-lactams/aminosides for PVGI, defined as positive bacterial culture of intraoperative specimens or blood samples and/or clinical, biological, and radiological signs of infection. Clinical success was defined by resolution of all clinical signs at the end of follow-up, without the need for additional antibiotic therapy, and/or negative culture in case of new surgery.

RESULTS

Cultures of intraoperative samples were positive in 21 patients (80.8%). Blood and intraoperative cultures were concomitantly positive in 10 patients. The main microorganism identified in microbiological samples was S. aureus (n = 18). Surgery was performed in 23 patients (88.4%). The mean duration of the DAP regimen was 12.3 ± 11.9 days. DAP was discontinued in 26 patients [need to switch to microbiological results (n = 19), bacterial pneumonia (n = 2), and increased creatine phosphokinase levels (n = 4)]. One patient had myalgia, while 9 received concomitant statins.

CONCLUSION

High-dose DAP therapy shows a satisfactory toxicity profile even in severely ill patients with multiple comorbidities, and may favorably compete with vancomycin, especially concerning the risk of induced nephrotoxicity.

Mycobacterium abscessus: a rare cause of vascular graft infection

Prosthetic vascular graft infection (PVGI) following vascular reconstructive surgery is an uncommon but serious complication and is associated with high morbidity as well as mortality rate. Staphylococcal species are the most common organisms causing PVGI. Mycobacterium abscessus is a very rare cause of PVGI and poses a significant diagnostic and management dilemma. To the best of our knowledge, we report the third documented case of M. abscessus vascular graft infection that was diagnosed with 18F-fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) scan and treated successfully.