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Extra-anatomic autologous reconstruction with hepatic-iliac artery bypass graft for aortic endograft infection
Extra-anatomic autologous reconstruction with hepatic-iliac artery bypass graft for aortic endograft infection Adelaide Buora, MD, Marco Floriani, MD, and Livio Gabrielli, MD, Milan, Italy We present a new intra-abdominal extra-anatomic bypass graft for a 64-year-old man treated with an abdominal aortic endograft and with signs of endograft infection. We performed surgical removal of the endograft and intra-abdominal extra-anatomic reconstruction of a hepatic-to-right external iliac artery bypass with autologous superficial femoral vein and a crossover graft between the right and left external iliac artery with the great saphenous vein. The later occlusion of the saphenous vein graft led us to perform a femoral-femoral prosthetic crossover. At 42 months from the intervention, the patient was in good health, and duplex scanning confirmed the patency of all grafts. (J Vasc Surg 2013;:1-3.)
Graft infection is a rare but serious complication that can occur after open or endovascular repair of an abdominal aortic aneurysm. The frequency of aortoiliac stent graft infection is estimated to be between 0.4% and 4%.1-3 Graft infection-related mortality is reported to be between 18% and 50%.3-5 The general consensus is that infected graft material should be completely removed and replaced with an in situ reconstruction or an extra-anatomic bypass graft. We describe a patient who we treated with an innovative approach with intermediate characteristics between an in situ reconstruction and an extra-anatomic bypass graft.
CASE REPORT A 64-year-old man affected by Stevens-Johnson syndrome and multiple allergies to antibiotics underwent in September 2009 endovascular repair of a right aortoiliac aneurysm in another hospital. In December 2009, a left common femoral artery pseudoaneurysm, that was apparently not infected and caused by arterial suture dehiscence, was observed and repaired. In February 2010, the patient developed signs of systemic sepsis with diffuse pain, weight loss, and persistent fever, for which he was admitted to the Division of Internal Medicine of our hospital. An abdominal computed tomography (CT) scan showed periprosthetic fluid and air within the aneurysm sac (Fig 1), and a labeled leukocyte scintigraphy confirmed the suspicion that the graft was infected. From the Vascular Surgery, Department of Clinical Sciences and Community Health, Ospedale Maggiore Policlinico, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda, University of Milan. Author conflict of interest: none. Reprint requests: Adelaide Buora, MD, Vascular Surgery, Department of Clinical Sciences and Community Health, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca’ Granda, University of Milan, via Francesco Sforza 35, 20122 Milan, Italy (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214/$36.00 Copyright Ó 2013 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2013.08.091
The patient was scheduled for surgical removal of the infected graft and in situ reconstruction with autologous vein. Median laparotomy and surgical exposure of the aortoiliac segments were performed, and the right superficial femoral vein and left saphenous vein were explanted. Exposure of the suprarenal segment of the aorta was attempted, without success, due to retroperitoneal inflammatory fibrosis involving the duodenum and making it inseparable from the aorta. We observed a small perforation of duodenal wall, probably due to the attempted cleavage, which was repaired with a double-layer suture. We clamped the supraceliac aorta and the iliac bifurcations. When the aneurysm sac was opened we observed a collection of pus that was sampled for cultural examination. The 30-mm-diameter Endurant graft (Medtronic, Minneapolis, Minn) was removed and sent for cultural examination. In consideration of the large infrarenal aortic diameter (26 mm), the anastomosis with the superficial femoral vein, even using a coaxial double vein graft technique, did not seem feasible. We therefore sutured the aortic stump with 2-0 Prolene (Ethicon, Somerville, NJ). The retroperitoneal space was carefully debrided and rinsed with iodinated solution. We decided to proceed with an intra-abdominal reconstruction to avoid the higher risk of reinfection connected with an axillobifemoral prosthetic bypass. The difficulty of performing an end-to-side anastomosis in the suprarenal aortic segment and the resulting contiguity of the duodenal dehiscence to the graft dissuaded us to use the aorta as the source of inflow. We therefore decided to use the common hepatic artery, which appeared to have an appropriate caliber and flow, as the source of inflow. We performed an end-to-side anastomosis between the common hepatic artery and the superficial femoral vein, with right paracolic retroperitoneal tunnelization of the venous segment and distal end-to-end anastomosis with the right external iliac artery (the common iliac artery was aneurysmatic and the internal iliac was occluded). The great saphenous vein was anastomosed endto-side with the grafted superficial femoral vein and then positioned in the submesenteric left retrocolic retroperitoneal space and distally anastomosed with the left external iliac artery. The duplex scan control showed triphasic blood flow in the femoral vein graft at declamping, whereas flow in the saphenous
1
JOURNAL OF VASCULAR SURGERY --- 2013
2 Buora et al
Fig 1. An axial-view preoperative computed tomography (CT) scan shows fluid collection and gas in the area of the graft.
Fig 3. A three-dimensional volume-rendered contrast computed tomography (CT) scan before discharge after the second operation shows no fluid or gas collections, a patent venous graft between the hepatic artery and the right iliac artery, and patency of the right-to-left crossover graft.
The patient showed a residual claudication of about 100 meters, and the ankle-brachial index on left anterior tibial artery decreased from 1 to 0.4. At 3 months after the first intervention, we decided to perform a femoral-to-femoral right-to-left bypass using an 8-mm Dacron (DuPont, Wilmington, Del) silver graft (Fig 3). CT scans 6, 12, and 24 months later confirmed the patency of all bypass grafts and no signs of infection. At 42 months from the first intervention, the patient was in good health, with no leg edema, and anterior tibial artery pulses were bilaterally present.
DISCUSSION Fig 2. A three-dimensional volume-rendered contrast computed tomography (CT) scan at 2 months from the surgery. vein segment had a lower diphasic signal. A pedunculated flap of omentum was transposed into retroperitoneal position and sutured to the aortic stump and to the duodenum. The patient’s postoperative course was unremarkable. Cultures of the intraoperatively collected specimens showed a Staphylococcus aureus infection, for which an antibiogramguided treatment with amoxicillin and clavulanate was started and continued for 60 days. The patient was discharged on postoperative day 18 with compressive stockings. At 2 months after surgery, a CT scan showed the resolution of all signs of abdominal infection, the patency of the right femoral vein graft, and the occlusion of the saphenous cross-over segment (Fig 2).
Endograft infection is a rare event but represents a challenging management problem in aortic surgery. Some authors suggest conservative treatment of the infection in selected patients,6-8 but conservative measures usually are associated with poor outcomes.9 The most widely accepted standard intervention is complete graft excision and local debridement, followed by the suture of the aortic stump and extra-anatomic revascularization through an axillobifemoral bypass graft. This procedure is definitely rational and relatively simple to perform but is not free of risk for severe complications, such as occlusion, reinfection of the prosthetic graft (especially in the setting of bacteremia), and rupture of the aortic suture line. Extra-anatomic reconstructions using autologous vein do not seem to be feasible.
JOURNAL OF VASCULAR SURGERY Volume -, Number -
This concern has led an increasing number of surgeons to consider an in situ reconstruction, using a Dacron or polytetrafluoroethylene prosthesis, rifampicin-bonded or rifampicin-gelatin grafts,10,11 human cryopreserved aorta, or treated heterologous grafts.12,13 Autologous vein for in situ reconstruction is considered the most effective means of avoiding reinfections14; the superficial femoral vein has favorable mechanical properties, with a 90% to 95% long-term patency.15,16 Removal of the superficial femoral vein is normally well tolerated, with rare cases of persistent lower limb edema requiring long-term compression. Considering the patient’s situationdpresence of duodenal dehiscence and a short and large aortic neck below the renal arteriesdwe believe that our solution should be considered in similar cases. Access to the hepatic artery is relatively easy, the vessel usually has a good caliber, is spared from significant atheromatosis, and can guarantee a good inflow. The position of the graft in the right paracolic space keeps it separated from the septic focus and from the possible consequences of a duodenal dehiscence. The same can hold true for the segment of the crossover graft running below the mesentery. We used the great saphenous vein as the crossover graft to avoid the surgical trauma of a bilateral femoral retrieval and because the saphenous vein seemed of good quality. We believe that early occlusion of the saphenous graft is occasional, probably due to an error in anastomotic technique or a low flow state and, therefore, not relevant in the choice of a mixed autologous solution. CONCLUSIONS We propose an alternative intra-abdominal reconstruction, based on an inflow from the hepatic artery, for patients with severe endovascular graft infection with duodenal fistula or marked discrepancy between the diameters of the infrarenal aorta and the venous graft. In the absence of these major risk factors, we are in favor of an in situ reconstruction from the aortic neck. REFERENCES 1. Heyer KS, Modi P, Morasch MD, Matsumura JS, Kibbe MR, Pearce WH, et al. Secondary infections of thoracic and abdominal aortic endografts. J Vasc Interv Radiol 2009;20:173-9.
Buora et al 3
2. Veraldi GF, Genco B, Minicozzi A, Zecchinelli MP, Segattini C, Momo RE, et al. Abdominal aortic endograft infection. Report of two cases and review of the literature. Chir Ital 2009;61:61-6. 3. Ducasse E, Calisti A, Speziale F, Rizzo L, Misuraca M, Fiorani P. Aortoiliac stent graft infection: current problems and management. Ann Vasc Surg 2004;18:521-6. 4. Sharif MA, Lee B, Lau LL, Ellis PK, Collins AJ, Blair PH, et al. Prosthetic stent graft infection after endovascular abdominal aortic aneurysm repair. J Vasc Surg 2007;46:442-8. 5. Cernohorsky P, Reijnen MP, Tielliu IF, van Sterkenburg SM, van den Dungen JA, Zeebregts CJ. The relevance of aortic endograft prosthetic infection. J Vasc Surg 2011;54:327-33. 6. Hulin SJ, Morris GE. Aortic endograft infection: open surgical management with endograft preservation. Eur J Vasc Endovasc Surg 2007;34:191-3. 7. Blanch M, Berjón J, Vila R, Simeon JM, Romera A, Riera S, et al. The management of aortic stent-graft infection: endograft removal versus conservative treatment. Ann Vasc Surg 2010;24:554.e1-5. 8. Jamieson RW, Burns PJ, Dawson AR, Fraser SCA. Aortic graft preservation by debridement and omental wrapping. Ann Vasc Surg 2012;26:423.e1-4. 9. Saleem BR, Meerwaldt R, Tielliu IFJ, Verhoeven EL, van den Dungen JJ, Zeebregts CJ. Conservative treatment of vascular prosthetic graft infection is associated with high mortality. Am J Surg 2010;200:47-52. 10. Uchida N, Katayama A, Tamura K, Miwa S, Masatsugu K, Sueda T. In situ replacement for mycotic aneurysms on the thoracic and abdominal aorta using rifampicin-bonded grafting and omental pedicle grafting. Ann Thorac Surg 2012;93:438-42. 11. Töpel I, Audebert F, Betz T, Steinbauer MG. Microbial spectrum and primary resistance to rifampicin in infectious complications in vascular surgery: limits to the use of rifampicin-bonded prosthetic grafts. Angiology 2010;61:423-6. 12. Ali AT, Modrall G, Hocking J, Valentine RJ, Spencer H, Eidt JF, et al. Long-term results of the treatment of aortic graft infection by in situ replacement with femoral popliteal vein grafts. J Vasc Surg 2009;50: 30-9. 13. Bown KE, Heyer K, Rodriguez H, Eskandari MK, Pearce WH, Morasch MD. Arterial reconstruction with cryopreserved human allografts in the setting of infection: a single-center experience with midterm follow-up. J Vasc Surg 2009;49:660-6. 14. O’Connor S, Andrew P, Batt M, Becquemin JP. A systematic review and meta-analysis of treatments for aortic graft infection. J Vasc Surg 2006;44:38-45. 15. Beck AV, Murphy EH, Hocking JA, Timaran CH, Arko FR, Clagett GP. Aortic reconstruction with femoral-popliteal vein: graft stenosis incidence, risk and reinterventions. J Vasc Surg 2008;47: 36-44. 16. Batt M, Jean-Baptiste E, O’Connor S, Bouillanne PJ, Haudebourg P, Hassen-Khodja R, et al. In-situ revascularization for patients with aortic graft infection: a single center experience with silver coated polyester grafts. Eur J Vasc Endovasc Surg 2008;36:182-8. Submitted Jul 9, 2013; accepted Aug 29, 2013.
Graft infection is a rare but serious complication that can occur after open or endovascular repair of an abdominal aortic aneurysm. The frequency of aortoiliac stent graft infection is estimated to be between 0.4% and 4%.1-3 Graft infection-related mortality is reported to be between 18% and 50%.3-5 The general consensus is that infected graft material should be completely removed and replaced with an in situ reconstruction or an extra-anatomic bypass graft. We describe a patient who we treated with an innovative approach with intermediate characteristics between an in situ reconstruction and an extra-anatomic bypass graft.
CASE REPORT A 64-year-old man affected by Stevens-Johnson syndrome and multiple allergies to antibiotics underwent in September 2009 endovascular repair of a right aortoiliac aneurysm in another hospital. In December 2009, a left common femoral artery pseudoaneurysm, that was apparently not infected and caused by arterial suture dehiscence, was observed and repaired. In February 2010, the patient developed signs of systemic sepsis with diffuse pain, weight loss, and persistent fever, for which he was admitted to the Division of Internal Medicine of our hospital. An abdominal computed tomography (CT) scan showed periprosthetic fluid and air within the aneurysm sac (Fig 1), and a labeled leukocyte scintigraphy confirmed the suspicion that the graft was infected. From the Vascular Surgery, Department of Clinical Sciences and Community Health, Ospedale Maggiore Policlinico, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda, University of Milan. Author conflict of interest: none. Reprint requests: Adelaide Buora, MD, Vascular Surgery, Department of Clinical Sciences and Community Health, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca’ Granda, University of Milan, via Francesco Sforza 35, 20122 Milan, Italy (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214/$36.00 Copyright Ó 2013 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2013.08.091
The patient was scheduled for surgical removal of the infected graft and in situ reconstruction with autologous vein. Median laparotomy and surgical exposure of the aortoiliac segments were performed, and the right superficial femoral vein and left saphenous vein were explanted. Exposure of the suprarenal segment of the aorta was attempted, without success, due to retroperitoneal inflammatory fibrosis involving the duodenum and making it inseparable from the aorta. We observed a small perforation of duodenal wall, probably due to the attempted cleavage, which was repaired with a double-layer suture. We clamped the supraceliac aorta and the iliac bifurcations. When the aneurysm sac was opened we observed a collection of pus that was sampled for cultural examination. The 30-mm-diameter Endurant graft (Medtronic, Minneapolis, Minn) was removed and sent for cultural examination. In consideration of the large infrarenal aortic diameter (26 mm), the anastomosis with the superficial femoral vein, even using a coaxial double vein graft technique, did not seem feasible. We therefore sutured the aortic stump with 2-0 Prolene (Ethicon, Somerville, NJ). The retroperitoneal space was carefully debrided and rinsed with iodinated solution. We decided to proceed with an intra-abdominal reconstruction to avoid the higher risk of reinfection connected with an axillobifemoral prosthetic bypass. The difficulty of performing an end-to-side anastomosis in the suprarenal aortic segment and the resulting contiguity of the duodenal dehiscence to the graft dissuaded us to use the aorta as the source of inflow. We therefore decided to use the common hepatic artery, which appeared to have an appropriate caliber and flow, as the source of inflow. We performed an end-to-side anastomosis between the common hepatic artery and the superficial femoral vein, with right paracolic retroperitoneal tunnelization of the venous segment and distal end-to-end anastomosis with the right external iliac artery (the common iliac artery was aneurysmatic and the internal iliac was occluded). The great saphenous vein was anastomosed endto-side with the grafted superficial femoral vein and then positioned in the submesenteric left retrocolic retroperitoneal space and distally anastomosed with the left external iliac artery. The duplex scan control showed triphasic blood flow in the femoral vein graft at declamping, whereas flow in the saphenous
1
JOURNAL OF VASCULAR SURGERY --- 2013
2 Buora et al
Fig 1. An axial-view preoperative computed tomography (CT) scan shows fluid collection and gas in the area of the graft.
Fig 3. A three-dimensional volume-rendered contrast computed tomography (CT) scan before discharge after the second operation shows no fluid or gas collections, a patent venous graft between the hepatic artery and the right iliac artery, and patency of the right-to-left crossover graft.
The patient showed a residual claudication of about 100 meters, and the ankle-brachial index on left anterior tibial artery decreased from 1 to 0.4. At 3 months after the first intervention, we decided to perform a femoral-to-femoral right-to-left bypass using an 8-mm Dacron (DuPont, Wilmington, Del) silver graft (Fig 3). CT scans 6, 12, and 24 months later confirmed the patency of all bypass grafts and no signs of infection. At 42 months from the first intervention, the patient was in good health, with no leg edema, and anterior tibial artery pulses were bilaterally present.
DISCUSSION Fig 2. A three-dimensional volume-rendered contrast computed tomography (CT) scan at 2 months from the surgery. vein segment had a lower diphasic signal. A pedunculated flap of omentum was transposed into retroperitoneal position and sutured to the aortic stump and to the duodenum. The patient’s postoperative course was unremarkable. Cultures of the intraoperatively collected specimens showed a Staphylococcus aureus infection, for which an antibiogramguided treatment with amoxicillin and clavulanate was started and continued for 60 days. The patient was discharged on postoperative day 18 with compressive stockings. At 2 months after surgery, a CT scan showed the resolution of all signs of abdominal infection, the patency of the right femoral vein graft, and the occlusion of the saphenous cross-over segment (Fig 2).
Endograft infection is a rare event but represents a challenging management problem in aortic surgery. Some authors suggest conservative treatment of the infection in selected patients,6-8 but conservative measures usually are associated with poor outcomes.9 The most widely accepted standard intervention is complete graft excision and local debridement, followed by the suture of the aortic stump and extra-anatomic revascularization through an axillobifemoral bypass graft. This procedure is definitely rational and relatively simple to perform but is not free of risk for severe complications, such as occlusion, reinfection of the prosthetic graft (especially in the setting of bacteremia), and rupture of the aortic suture line. Extra-anatomic reconstructions using autologous vein do not seem to be feasible.
JOURNAL OF VASCULAR SURGERY Volume -, Number -
This concern has led an increasing number of surgeons to consider an in situ reconstruction, using a Dacron or polytetrafluoroethylene prosthesis, rifampicin-bonded or rifampicin-gelatin grafts,10,11 human cryopreserved aorta, or treated heterologous grafts.12,13 Autologous vein for in situ reconstruction is considered the most effective means of avoiding reinfections14; the superficial femoral vein has favorable mechanical properties, with a 90% to 95% long-term patency.15,16 Removal of the superficial femoral vein is normally well tolerated, with rare cases of persistent lower limb edema requiring long-term compression. Considering the patient’s situationdpresence of duodenal dehiscence and a short and large aortic neck below the renal arteriesdwe believe that our solution should be considered in similar cases. Access to the hepatic artery is relatively easy, the vessel usually has a good caliber, is spared from significant atheromatosis, and can guarantee a good inflow. The position of the graft in the right paracolic space keeps it separated from the septic focus and from the possible consequences of a duodenal dehiscence. The same can hold true for the segment of the crossover graft running below the mesentery. We used the great saphenous vein as the crossover graft to avoid the surgical trauma of a bilateral femoral retrieval and because the saphenous vein seemed of good quality. We believe that early occlusion of the saphenous graft is occasional, probably due to an error in anastomotic technique or a low flow state and, therefore, not relevant in the choice of a mixed autologous solution. CONCLUSIONS We propose an alternative intra-abdominal reconstruction, based on an inflow from the hepatic artery, for patients with severe endovascular graft infection with duodenal fistula or marked discrepancy between the diameters of the infrarenal aorta and the venous graft. In the absence of these major risk factors, we are in favor of an in situ reconstruction from the aortic neck. REFERENCES 1. Heyer KS, Modi P, Morasch MD, Matsumura JS, Kibbe MR, Pearce WH, et al. Secondary infections of thoracic and abdominal aortic endografts. J Vasc Interv Radiol 2009;20:173-9.
Buora et al 3
2. Veraldi GF, Genco B, Minicozzi A, Zecchinelli MP, Segattini C, Momo RE, et al. Abdominal aortic endograft infection. Report of two cases and review of the literature. Chir Ital 2009;61:61-6. 3. Ducasse E, Calisti A, Speziale F, Rizzo L, Misuraca M, Fiorani P. Aortoiliac stent graft infection: current problems and management. Ann Vasc Surg 2004;18:521-6. 4. Sharif MA, Lee B, Lau LL, Ellis PK, Collins AJ, Blair PH, et al. Prosthetic stent graft infection after endovascular abdominal aortic aneurysm repair. J Vasc Surg 2007;46:442-8. 5. Cernohorsky P, Reijnen MP, Tielliu IF, van Sterkenburg SM, van den Dungen JA, Zeebregts CJ. The relevance of aortic endograft prosthetic infection. J Vasc Surg 2011;54:327-33. 6. Hulin SJ, Morris GE. Aortic endograft infection: open surgical management with endograft preservation. Eur J Vasc Endovasc Surg 2007;34:191-3. 7. Blanch M, Berjón J, Vila R, Simeon JM, Romera A, Riera S, et al. The management of aortic stent-graft infection: endograft removal versus conservative treatment. Ann Vasc Surg 2010;24:554.e1-5. 8. Jamieson RW, Burns PJ, Dawson AR, Fraser SCA. Aortic graft preservation by debridement and omental wrapping. Ann Vasc Surg 2012;26:423.e1-4. 9. Saleem BR, Meerwaldt R, Tielliu IFJ, Verhoeven EL, van den Dungen JJ, Zeebregts CJ. Conservative treatment of vascular prosthetic graft infection is associated with high mortality. Am J Surg 2010;200:47-52. 10. Uchida N, Katayama A, Tamura K, Miwa S, Masatsugu K, Sueda T. In situ replacement for mycotic aneurysms on the thoracic and abdominal aorta using rifampicin-bonded grafting and omental pedicle grafting. Ann Thorac Surg 2012;93:438-42. 11. Töpel I, Audebert F, Betz T, Steinbauer MG. Microbial spectrum and primary resistance to rifampicin in infectious complications in vascular surgery: limits to the use of rifampicin-bonded prosthetic grafts. Angiology 2010;61:423-6. 12. Ali AT, Modrall G, Hocking J, Valentine RJ, Spencer H, Eidt JF, et al. Long-term results of the treatment of aortic graft infection by in situ replacement with femoral popliteal vein grafts. J Vasc Surg 2009;50: 30-9. 13. Bown KE, Heyer K, Rodriguez H, Eskandari MK, Pearce WH, Morasch MD. Arterial reconstruction with cryopreserved human allografts in the setting of infection: a single-center experience with midterm follow-up. J Vasc Surg 2009;49:660-6. 14. O’Connor S, Andrew P, Batt M, Becquemin JP. A systematic review and meta-analysis of treatments for aortic graft infection. J Vasc Surg 2006;44:38-45. 15. Beck AV, Murphy EH, Hocking JA, Timaran CH, Arko FR, Clagett GP. Aortic reconstruction with femoral-popliteal vein: graft stenosis incidence, risk and reinterventions. J Vasc Surg 2008;47: 36-44. 16. Batt M, Jean-Baptiste E, O’Connor S, Bouillanne PJ, Haudebourg P, Hassen-Khodja R, et al. In-situ revascularization for patients with aortic graft infection: a single center experience with silver coated polyester grafts. Eur J Vasc Endovasc Surg 2008;36:182-8. Submitted Jul 9, 2013; accepted Aug 29, 2013.