- Email: [email protected]
Neoaortoiliac System Procedure to Treat Infected Aortic Grafts
Accepted Manuscript Neoaortoiliac System procedure to treat infected aortic grafts Chris Klonaris, Nikolaos Patelis, Athanasios Katsargyris, Dimitrios Athanasiadis, Andreas Alexandrou, Theodoros Liakakos PII:
S0890-5096(17)30684-2
DOI:
10.1016/j.avsg.2017.04.041
Reference:
AVSG 3379
To appear in:
Annals of Vascular Surgery
Received Date: 19 March 2017 Revised Date:
23 April 2017
Accepted Date: 25 April 2017
Please cite this article as: Klonaris C, Patelis N, Katsargyris A, Athanasiadis D, Alexandrou A, Liakakos T, Neoaortoiliac System procedure to treat infected aortic grafts, Annals of Vascular Surgery (2017), doi: 10.1016/j.avsg.2017.04.041. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Neoaortoiliac System procedure to treat infected aortic grafts
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Chris Klonarisa1, Nikolaos Patelisa1, Athanasios Katsargyris2, Dimitrios Athanasiadis1,
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Andreas Alexandrou1, Theodoros Liakakos1
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Affiliations
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University of Athens, Laiko General Hospital, Greece
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Germany
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Authors equally contributing
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First Department of Surgery, Vascular Division, Medical School, National & Kapodistrian
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Department of Vascular & Endovascular Surgery, Paracelsus Medical University, Nuremberg,
Corresponding Author:
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Dr Nikolaos Patelis, MD, MSc, PhD(c)
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First Department of Surgery, Vascular Division, Medical School, National & Kapodistrian University of Athens, Laiko General Hospital
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17 Ag.Thoma St, 11527 Athens, Greece
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Tel: 2107456243, email: [email protected]
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Funding: No funding was received
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Conflict of interest: No conflict of interest to disclose
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ACCEPTED MANUSCRIPT Neoaortoiliac System procedure to treat infected aortic grafts
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Abstract
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Objective: The aim of this case series is to report the results of our centre in the surgical
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treatment of infected abdominal aortic grafts using the neo-aortoiliac system (NAIS) procedure.
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Patients and Methods: Four male and two female patients underwent a NAIS repair after
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endovascular (n=3), open (n=2) or combined surgery (n=1) in our centre. Mean age was 73±5.2
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years. Graft infection was diagnosed by computed tomography angiography (CTA) and only in
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two cases further imaging was necessary. The diagnosis was set at average 6.2 years after the
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initial procedure.
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Results: Four patients underwent a standard pantaloon NAIS procedure, one patient with a
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small aortic diameter received one femoral vein as aorto-aortic interposition graft and one
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patient received a unilateral aorto-iliac by-pass; all patients received autologous femoral veins
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grafts. Thirty-day mortality was zero, with in-hospital mortality of one patient (16.7%). Mean
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hospital stay was 27±4.9 days, with mean ICU stay of 2.2 days (range 1-3). During follow-up
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(mean 6.17 months, range 1-24 months), two patients presented with thigh wound
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complications, one of which required surgical revision. One patient was re-admitted due to
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upper gastrointestinal (GI) bleeding as a side effect of anticoagulation, without the presence of
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ulcer or other GI pathology.
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Conclusion: In our early experience NAIS showed to be a demanding procedure for both the
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patient and the surgical team. It avoids however the disadvantages of extra-anatomic by-pass
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and other methods used to treat aortic graft infection. Larger study groups are necessary to
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support these findings.
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ACCEPTED MANUSCRIPT Neoaortoiliac System procedure to treat infected aortic grafts
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Introduction
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The use of various types of synthetic grafts is nowadays common for both open (OAR) and
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endovascular (EVAR) repair of aortic aneurysms in emergency or elective cases. (1-3)
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Complications of the use of synthetic grafts in either OAR or in EVAR are increasingly
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reported and one of the most morbid and complex complications is graft infection. (3) With a
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reported incidence of 0.2-6%, graft infection is a rather uncommon complication, and therefore
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not well studied. (3, 4)
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Treatment plan for graft infection includes medical treatment with antibiotics, graft removal,
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infectious loci debridement and consequently revascularization of the lower limbs. Some
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authors suggest alternatively a more conservative management with preservation of the infected
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graft and antibiotic irrigation (5). If graft removal is decided, revascularization of the lower
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limbs can be achieved with different methods, including ligation of the aorta and extra-
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anatomic by-pass, in-situ use of cryo-preserved aortic allograft or antiobiotic-soaked prosthetic
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grafts, or neoaortoiliac system (NAIS) reconstruction using the femoral veins (FVs) of the
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patient. The latter method was first described by Clagett et al in 1993 (6) . In this publication,
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our centre’s experience with the NAIS procedure to treat aortic graft infection is described.
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Materials and methods
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This study included all patients that underwent a NAIS procedure within the period January
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2015-December 2016 in our institution. Before January 2015, aortic graft infections were
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treated with infrarenal aortic ligation and extra-anatomic axillo-bifemoral-bypass graft.
ACCEPTED MANUSCRIPT Data were collected prospectively. All patients provided their informed consent.
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Indications for the NAIS procedure included the presence of an infected aortic graft after
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previous open or endovascular aortic reconstruction for abdominal aortic aneurysm (AAA) or
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aortoiliac occlusive disease. All patients had received antibiotic treatment for a period of time
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in our or other institutions before surgical treatment was considered. Surgical treatment was
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considered only after failure of medical treatment.
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The diagnosis of graft infection was based on clinical and laboratory status of the patients along
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with imaging findings in CT-Angiography (CTA) and Fluorodeoxyglucose (FDG)-positron
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emission tomography (PET). Endoscopy was not part of the pre-operative diagnostic strategy,
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but performed only in cases of patients presenting with upper or lower GI bleeding. Endoscopy
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examination in these patients consisted of esophagogastroduodenoscopy as the first step,
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followed by lower GI flexible endoscopy.
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Physical status of the patients was assessed by an anesthesiologist of our hospital. All patients
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had a thorough preoperative work-up including echocardiography and lung function tests
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before proceeding with the operation. Frail patients were excluded. Anatomical criteria were
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also considered before proceeding with planning of the operation. Patients with inadequate
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cumulative length or small caliber (<11mm in females, <12mm in males) (7) FVs were
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excluded from undergoing a NAIS procedure. Therefore all patients underwent ultrasound
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study of FVs before a definite decision for NAIS was taken.
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Patients who did not meet the physical and anatomical criteria for a NAIS procedure were
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planned for an extra-anatomical bypass. Patients that were initially considered suitable to
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undergo a NAIS procedure, but intraoperative findings prevented a NAIS reconstruction,
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received also an extra-anatomical bypassIn this case, the decision was made intraoperatively by
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the chief vascular surgeon.
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ACCEPTED MANUSCRIPT Procedure
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The procedure was initiated with a median laparotomy in a standard fashion. The sub-
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diaphragmatic aorta was always exposed to achieve proximal control if needed. Subsequently
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the abdominal aorta and iliac arteries were exposed and the aortic graft explanted. Total
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resection of the infected graft was always planned. Partial graft excision was avoided, in an
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attempt to eradicate any possible source of persisting/recurrent infection.
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If the quality of the remaining aortic neck after graft explantation was considered acceptable for
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a NAIS reconstruction, the superficial femoral veins were thereafter removed. In case of a
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scheduled bilateral iliac reconstruction the two femoral veins were prepared and sewn in a
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pantaloon configuration.
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Whenever a deficit in the duodenal wall was identified it was always hand-sewn primarily, with
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a double-layer, single stitches, vicryl 3-0 internal layer, PDS 3-0 external layer technique. An
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omental flap was then created and secured above the duodenal closure. A Penrose drain was
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always left in proximity with the duodenal reconstruction. Drains were also always left in the
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femoral wounds.
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Postoperatively the nasogastric tube (NGT) was kept in place for 5-7 days. Upper
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gastrointestinal tract (GI) series were not regularly performed before the NGT’s removal. All
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patients received anticoagulation with daily subcutaneous injection of low molecular weight
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heparin (LMWH) and proton pump inhibitors for 1 month. All patients underwent targeted
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antibiotic treatment for up to six weeks. The respective antibiotic regime for each patient was
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decided by a multi-disciplinary team consisting of the vascular unit specialists and
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infectiologists.
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Follow-up regime consists of CTA on 1st, 6th, and 12th postoperative month, and yearly
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thereafter. Blood cultures, C-reactive protein and total blood counts are repeated weekly for the
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first month after discharge, and then repeated along the imaging protocol for the first
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postoperative
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if
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necessary.
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During the study period a total of seven patients were treated for aortic graft infection. In one
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patient, aortic ligation with axillo-bi-femoral bypass was performed because the posterior wall
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of the remaining aortic neck after explantation of the graft was judged of poor quality for a safe
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NAIS procedure. Therefore, 6 patients (four male, mean age 73±5.2 years) were treated with
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the NAIS procedure and are described below. Patients’ demographics are shown in Table 1.
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Three patients had undergone an EVAR, one patient an open AAA repair, and one patient had
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an aortic tube graft for aortic stenosis. The remaining patient had a complex past surgical
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history of initial open AAA repair and a consequent aorto-monoiliac endovascular repair with a
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femoro-femoral by-pass due to a proximal para-anastomotic aneurysm 5 years after the primary
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procedure. Five patients presented with fever and poor general status. Two patients presented
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with GI bleeding; one patient had no findings in endoscopy and one had thrombus in the third
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segment of the duodenum. Lower GI endoscopy was negative for both these patients. Previous
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blood cultures performed before referral were positive for Streptococcus mitis (1 patient),
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Methicillin-resistant Staphylococcus aureus or MRSA (2 patients) and Staphylococcus
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epidermidis (2 patients). One patient had never had positive blood cultures. All patients had
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received long-term antibiotic treatment and had negative blood cultures before being referred to
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our department. Despite proper antibiotic treatment, one patient had a positive blood culture
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for MRSA during his hospitalization in our department. All patients presented with
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leukocytosis and elevated serum C-reactive protein levels.
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The diagnosis of graft infection wasset at average 6.2 years (range 9 months-15 years) after the
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initial graft implantation. Findings in CT scan included peri-graft gas, thickening of the peri-
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ACCEPTED MANUSCRIPT graft tissues and in three cases an adherence of the duodenum to the graft. (Fig 1.)
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Fluorodeoxyglucose (FDG)-positron emission tomography (PET) was utilized by the referring
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physicians for proper diagnosis in two cases; in one case to exclude other possible infection
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sites, and in another case to ensure that the femoro-femoral by-pass graft of the patient is not
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infected.
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Four patients underwent pantaloon NAIS with the use of both FVs. One patient with previous
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tubing of a very small aorta treated for stenosis received one FV as aorto-aortic interposition
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graft. One patient underwent a unilateral NAIS procedure to the right common iliac artery
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(CIA) while a previously implanted femoro-femoral by-pass was still patent, without signs of
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infection. In one case a duodenal exclusion with a concomitant gastrojejunal anastomosis was
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performed due to unfavorable local conditions. Mean procedure time was 510 ± 65 minutes.
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Thirty-day mortality was zero, with in-hospital mortality of one patient (16.7%). This patient
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died on the 37th postoperative day due to complications from severe cholangiitis and
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overwhelming sepsis. Two patients developed thigh wound complications, one required
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surgical revision. Mean ICU stay was 2.2 days (range 1-3) and mean hospital stay was 27±4.9
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days (range 19-34 days). Graft material cultures were positive for S. epidermidis in two patients
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and for MRSA in one, while the rest had negative graft material cultures. During follow-up
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(mean 6.17 months, range 1-24 months) one patient was re-admitted due to upper
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gastrointestinal (GI) bleeding as a side effect of anticoagulation, without the presence of ulcer
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or other GI pathology.
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Discussion
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Aortic graft infection following infrarenal aortic reconstruction is (8) one of the most morbid
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complications in vascular surgery (8). Management of infected aortic grafts ranges from more
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conservative options (systemic antibiotic treatment, local antibiotic or antiseptic lavage,
ACCEPTED MANUSCRIPT surgical debridement of the infected peri-graft tissue) to radical excision of the infected graft.
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The use of stent grafts mainly as a "bridging" option in high-risk patients with delayed
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definitive surgical management is also reported. (9-12).
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Upon excision of the infected graft, revascularisation is achieved in anatomic or extra-anatomic
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fashion using an autologous graft, a cryopreserved allograft, or a synthetic graft. (13) Extra-
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anatomic revascularization after aortic ligation is associated with a risk for aortic stump
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blowout, and suboptimal long-term patency. Additionally the use of a synthetic extra-anatomic
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by-pass graft can lead to an increased rate of infection recurrence. In situ anatomic
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revascularisation with a new synthetic graft (either bare or antibiotic-soaked) often leads to
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recurrent infection. Cryopreserved allografts can be alternatively used for anatomic
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revascularization, but these grafts are not available in all centers including ours. (3). (13). (14,
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15)
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In 1993, Clagett et al. described the NAIS as the aortic reconstruction method to be used after
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aortic graft infection and graft excision, an idea based on the work of Schulman et al., who first
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used the FV as a conduit for femoro-popliteal by-pass. (6) The procedure of FV harvesting has
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been reported in great detail, as well as potential tricks and pitfalls of the procedure, and it
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consists of in situ reconstruction of the aorta using the FVs of the patient. (6, 16-18) In those
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cases where both FVs are of proper size and both excised, the result of this method is a
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reinfection-resistant neo-aorta of similar caliber to the original aorta. In patients with FVs of
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inadequate length (<30cm) or diameter, one FV can be used to by-pass the aortic flow to one
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common iliac artery along with another by-pass utilizing either the shorter FV, the great
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saphenous vein or a synthetic conduit for the contralateral limb. (19) FVs or FVs of patients,
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who have undergone CABG or other revascularization procedures, might not be available for
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harvesting. Severe femoro-popliteal arterial diseases and previously performed saphenectomy
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may be relative contraindications for NAIS. It is obvious that careful and detailed preoperative
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ACCEPTED MANUSCRIPT planning is essential for the technical success of the NAIS procedure.
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Clearly not all patients presenting with aortic graft infection are suitable for the NAIS
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procedure. The overall clinical status of the patient should be carefully evaluated preoperatively
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including detailed assessment of the cardiorespiratory capacity as previously described. A
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thorough imaging and laboratory work-up is also of significant importance in order to securely
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establish the diagnosis of graft infection, before jumping quickly to a highly morbid procedure
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as the NAIS. The NAIS procedure was undertaken only after diagnosis of graft infection and
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approval of the vascular anesthesiology team regarding the physical status of the patient.
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In poor surgical candidates a more conservative approach can be considered, such as
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percutaneous peri-aortic drainage, graft lavage, or omental flap. Reported results show that
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these methods do have a place in current aortic graft treatment, although they should be
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generally considered for frail patients who cannot undergo intensive and demanding surgery.
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(20) Although successful treatment of aortic graft by the above-described less invasive methods
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is reported as single cases in literature (21-25), the main disadvantage of these methods is the
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inability to eradicate the infection completely, which is linked to high complication and
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morbidity rates. (20) Additionally, graft preservation is not a choice of treatment in cases with
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an AEF present or in grafts infected with Gram-negative species. (26) On the other hand
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surgical treatment for aortic graft infection is also linked to substantial complication and
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morbidity rates that differ between various approaches. (27) Further research is necessary to
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establish when minimally invasive or conservative treatment for aortic graft infection is safe
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and efficient, as existing data is both limited and contradicting. (8, 26, 28)
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Every effort should be also undertaken, pre-operatively, intra-operatively and post-operatively
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for identification of the cause of the infection, given the different treatment regimen and
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prognosis according to each infecting agent. In our series preoperative identification of the
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ACCEPTED MANUSCRIPT infecting agent was not always possible, something that is already reported as a common
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finding in literature. (29) Bacteria identified in our cases were also in line with already
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published findings. (29, 30) S. epidermidis is considered a low virulence micro-organism, while
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the presence of S. aureus or MRSA is a significant risk factor for the patient; all three bacteria
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were found in some of the patients in this series. (30) Streptococcus mitis is a Gram-positive
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coccus, facultative anaerobe and catalase negative micro-organism, part of the natural human
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microbiota, which has been rarely reported as a microbial agent in aortic graft infection. (31)
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In most case series, early and 5-year mortality is reported to be in the range of 10% and 50%
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respectively. (13, 18, 32) Long-term patency after NAIS is reported to be higher than any other
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modality, reaching primary patency rate higher than 86% at 5 years, and a cumulative
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secondary patency rate as high as 100%. (4, 18, 33-35). Early patency in our cases is 100%
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but as the mean follow-up period is 6 months long-term patency cannot be reported yet.
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Although complications related to aortic-ligation and extra-anatomical bypasses might be
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avoided, NAIS carries its own related complications. Complications related to the thigh
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incisions include haemorrhage, infection, and dehiscence. (4, 32) Two of our patients had thigh
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wound-related complications, one of which required surgical revision. Complications also arise
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from inadequate venous return, presenting with usually temporary limb edema but in rare cases
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with compartment syndrome. (4, 32) In our cases, light to mediate edema was present in three
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limbs, but it has resolved spontaneously without any need for additional interventions. Another
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method-related complication is graft stenosis, with a reported prevalence varying from 4.6% to
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as high as 23.5%. (4, 13, 34, 36) Graft stenosis is more common when FVs of small diameter
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are used to re-establish aorto-iliac continuity, in smokers and in patients with coronary artery
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disease. Aneurysmal degeneration of the FV may also be a concern in the long-term. These
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patients should therefore undergo vigorous follow-up. A scheduled surveillance protocol,
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ACCEPTED MANUSCRIPT consisting of laboratory as well as CTA and ultrasound investigations is mandatory.
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Furthermore a long-lasting antibiotic therapy may be considered. (19)
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NAIS remains a demanding procedure for both the patient and the vascular team. The
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procedure time is usually long, but the simultaneous work of a second surgical team can
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potentially reduce it by two hours. (18, 33) Staging of the NAIS procedure, with FVs harvested
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one day earlier than the revascularization procedure is also reported.(33) Both these tactics
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however, run the risk of harvesting the FVs without finally being used, in case of poor aortic
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neck wall quality that precludes a NAIS procedure. In our centre, the aorta is first exposed and
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the infected graft removed, and if the remaining aortic wall is judged of adequate quality for an
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anastomosis, then FV harvesting is performed by the same surgical team.
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Despite the existing unsolved questions whether conservative, minimally invasive or surgical
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treatment is best for treating aortic graft infections, our team considers NAIS to be an attractive
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solution to this grave complication of aortic surgery when patients are carefully selected; a
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common consideration that exists in many centres. (27)
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Conclusion
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Our preliminary experience with the NAIS procedure seems encouraging. The operation is
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technically demanding, but once successful it offers complete eradication of the infection,
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without compromising lower-extremity perfusion. An intensive tracking of peri-operative and
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long-term follow-up results is warranted, in order to establish the role of this technique as
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standard of practice, at least in selected high-volume vascular centers.
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References: 1. Steuer J, Lachat M, Veith FJ, Wanhainen A. Endovascular grafts for abdominal aortic aneurysm. Eur Heart J. 2016;37(2):145-51. 2. Patelis N, Moris D, Karaolanis G, Georgopoulos S. Endovascular vs. Open Repair for Ruptured Abdominal Aortic Aneurysm. Medical science monitor basic research. 2016;22:34-44. 3. Smeds MR, Duncan AA, Harlander-Locke MP, Lawrence PF, Lyden S, Fatima J, et al. Treatment and outcomes of aortic endograft infection. J Vasc Surg. 2016;63(2):332-40. 4. Kilic A, Arnaoutakis DJ, Reifsnyder T, Black JH, 3rd, Abularrage CJ, Perler BA, et al. Management of infected vascular grafts. Vascular medicine. 2016;21(1):53-60. 5. Akhtar M, Meecham L, Birkett R, Pherwani AD, Fairhead JF. Conservative Treatment of an Infected Aortic Graft with Antibiotic Irrigation. Int J Angiol. 2016;25(5):e118-e20. 6. Clagett GP, Bowers BL, Lopez-Viego MA, Rossi MB, Valentine RJ, Myers SI, et al. Creation of a neo-aortoiliac system from lower extremity deep and superficial veins. Ann Surg. 1993;218(3):239-48; discussion 48-9. 7. Fronek A, Criqui MH, Denenberg J, Langer RD. Common femoral vein dimensions and hemodynamics including Valsalva response as a function of sex, age, and ethnicity in a population study. J Vasc Surg. 2001;33(5):1050-6. 8. Debus ES, Diener H. Reconstructions Following Graft Infection: An Unsolved Challenge. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2016. 9. Carrel T, Schmidli J. Management of vascular graft and endoprosthetic infection of the thoracic and thoraco-abdominal aorta. Multimed Man Cardiothorac Surg. 2011;2011(1101):mmcts 2010 004705. 10. Kotsis T, Lioupis C, Tzanis A, Nasiopoulou P, Goumas K, Bakoyiannis K, et al. Endovascular repair of a bleeding secondary aortoenteric fistula with acute leg ischemia: a case report and review of the literature. Journal of vascular and interventional radiology : JVIR. 2006;17(3):563-7. 11. Lonn L, Dias N, Veith Schroeder T, Resch T. Is EVAR the treatment of choice for aortoenteric fistula? J Cardiovasc Surg (Torino). 2010;51(3):319-27. 12. Verma H, Mohan S, Tripathi RK. Pantaloon femoral vein graft as "neoaorta" in infected aortic disease. J Vasc Surg. 2015;62(4):1083-8. 13. Ali AT, Modrall JG, 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(1):30-9. 14. Kahlberg A, Melissano G, Tshomba Y, Leopardi M, Chiesa R. Strategies to treat thoracic aortitis and infected aortic grafts. J Cardiovasc Surg (Torino). 2015;56(2):269-80. 15. Goeau-Brissonniere O, Leport C, Guidoin R, Lebrault C, Pechere JC, Bacourt F. Experimental colonization of an expanded polytetrafluoroethylene vascular graft with Staphylococcus aureus: a quantitative and morphologic study. J Vasc Surg. 1987;5(5):743-8. 16. Smith ST, Clagett GP. Femoral vein harvest for vascular reconstructions: pitfalls and tips for success. Seminars in vascular surgery. 2008;21(1):35-40. 17. Valentine RJ. Harvesting the superficial femoral vein as an autograft. Seminars in vascular surgery. 2000;13(1):27-31.
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18. Chung J, Clagett GP. Neoaortoiliac System (NAIS) procedure for the treatment of the infected aortic graft. Seminars in vascular surgery. 2011;24(4):220-6. 19. Lopera JE, Trimmer CK, Josephs S, Dolmatch B, Valentine RJ, Clagett GP. Neoaortoiliac reconstructions using femoropopliteal veins: MDCT angiography findings. AJR American journal of roentgenology. 2008;191(2):569-77. 20. Igari K, Kudo T, Toyofuku T, Jibiki M, Sugano N, Inoue Y. Treatment strategies for aortic and peripheral prosthetic graft infection. Surgery today. 2014;44(3):466-71. 21. Hulin SJ, Morris GE. Aortic endograft infection: open surgical management with endograft preservation. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2007;34(2):191-3. 22. Mo A, Lin H. Successful therapy for a patient with aortic graft infection without graft removal. Annals of vascular surgery. 2011;25(5):698 e1-4. 23. Gordon A, Conlon C, Collin J, Peto T, Gray D, Hands L, et al. An eight year experience of conservative management for aortic graft sepsis. Eur J Vasc Surg. 1994;8(5):611-6. 24. Morris GE, Friend PJ, Vassallo DJ, Farrington M, Leapman S, Quick CR. Antibiotic irrigation and conservative surgery for major aortic graft infection. J Vasc Surg. 1994;20(1):88-95. 25. Quick CR, Vassallo DJ, Colin JF, Heddle RM. Conservative treatment of major aortic graft infection. Eur J Vasc Surg. 1990;4(1):63-7. 26. Lawrence PF. Conservative treatment of aortic graft infection. Seminars in vascular surgery. 2011;24(4):199-204. 27. Heinola I, Kantonen I, Jaroma M, Alback A, Vikatmaa P, Aho P, et al. Editor's Choice - Treatment of Aortic Prosthesis Infections by Graft Removal and In Situ Replacement with Autologous Femoral Veins and Fascial Strengthening. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2016;51(2):232-9. 28. Ohta T, Hosaka M, Ishibashi H, Sugimoto I, Takeuchi N, Kazui H, et al. Treatment for aortic graft infection. Surgery today. 2001;31(1):18-26. 29. FitzGerald SF, Kelly C, Humphreys H. Diagnosis and treatment of prosthetic aortic graft infections: confusion and inconsistency in the absence of evidence or consensus. J Antimicrob Chemother. 2005;56(6):996-9. 30. Hodgkiss-Harlow KD, Bandyk DF. Antibiotic therapy of aortic graft infection: treatment and prevention recommendations. Seminars in vascular surgery. 2011;24(4):191-8. 31. Leseche G, Castier Y, Petit MD, Bertrand P, Kitzis M, Mussot S, et al. Long-term results of cryopreserved arterial allograft reconstruction in infected prosthetic grafts and mycotic aneurysms of the abdominal aorta. J Vasc Surg. 2001;34(4):616-22. 32. Budtz-Lilly J, Eldrup N, Vammen S, Laustsen J. Femoral vein repair of arterial infections: technical tips to reduce procedure time. Vasc Endovascular Surg. 2014;48(5-6):367-71. 33. Ali AT, McLeod N, Kalapatapu VR, Moursi MM, Eidt JF. Staging the neoaortoiliac system: feasibility and short-term outcomes. J Vasc Surg. 2008;48(5):1125-30; discussion 30-1.
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34. Beck AW, Murphy EH, Hocking JA, Timaran CH, Arko FR, Clagett GP. Aortic reconstruction with femoral-popliteal vein: graft stenosis incidence, risk and reintervention. J Vasc Surg. 2008;47(1):36-43; discussion 4. 35. Modrall JG, Sadjadi J, Joiner DR, Ali A, Welborn MB, 3rd, Jackson MR, et al. Comparison of superficial femoral vein and saphenous vein as conduits for mesenteric arterial bypass. J Vasc Surg. 2003;37(2):362-6. 36. Faulk J, Dattilo JB, Guzman RJ, Naslund TC, Passman MA. Neoaortic reconstruction for aortic graft infection: need for endovascular adjunctive therapies? Annals of vascular surgery. 2005;19(6):774-81.
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Table I: Patients’ demographics and data. Gender
Age
Present ing Sympto ms
Comorbidities
Initial Operation
Timeframe since 1st repair
Procedure
Pantaloon NAIS with FVs;
F
80
Fever, poor status
Hypertension, dyslipidemia
EVAR
2 years
2
M
75
CABG, hypertension
EVAR
9 months
3
M
76
Poor status, low grade fever GI bleedin g Fever, lower GI bleedin g
Partial gastrectomy, hypertension, AF
Open AAA repair; Aortomonoiliac EVAR for paraanastomotic aneurysm and femoro-femoral bypass 5 yrs later
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Pantaloon NAIS with FVs;
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Complications
Reintervention
Thigh hematoma
Hematoma drainage
Bilateral thigh wounds dehiscence
No
In-hospital death due to acute cholangiitis
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NAIS to right CIA with FV (previous femorofemoral bypass patent)
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65
Poor status, low grade fever
Hypertension, dyslipidemia
Aortic tubing for aortic stenosis
15 years
One FV as Aorto-aortic interposition graft
5
M
70
Fever
CABG, hypertension
Open AAA repair
2 years
Pantaloon NAIS with FVs
6
M
72
Low grade Fever
hypertension, DM
EVAR
3 years
Pantaloon NAIS with FVs
Upper GI bleeding due to anticoagulation
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No
-
No
-
No
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EVAR – endovascular aneurysm repair; CABG – coronary artery bypass graft; FV – femoral vein; CIA – common iliac artery; AF – atrial fibrillation; NAIS – neoaortoiliac system; DM – diabetes mellitus; GI- gastrointestinal; AAA –abdominal aortic aneurysm
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S0890-5096(17)30684-2
DOI:
10.1016/j.avsg.2017.04.041
Reference:
AVSG 3379
To appear in:
Annals of Vascular Surgery
Received Date: 19 March 2017 Revised Date:
23 April 2017
Accepted Date: 25 April 2017
Please cite this article as: Klonaris C, Patelis N, Katsargyris A, Athanasiadis D, Alexandrou A, Liakakos T, Neoaortoiliac System procedure to treat infected aortic grafts, Annals of Vascular Surgery (2017), doi: 10.1016/j.avsg.2017.04.041. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Neoaortoiliac System procedure to treat infected aortic grafts
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Chris Klonarisa1, Nikolaos Patelisa1, Athanasios Katsargyris2, Dimitrios Athanasiadis1,
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Andreas Alexandrou1, Theodoros Liakakos1
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a
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Affiliations
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1
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University of Athens, Laiko General Hospital, Greece
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2
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Germany
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Authors equally contributing
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First Department of Surgery, Vascular Division, Medical School, National & Kapodistrian
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Department of Vascular & Endovascular Surgery, Paracelsus Medical University, Nuremberg,
Corresponding Author:
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Dr Nikolaos Patelis, MD, MSc, PhD(c)
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First Department of Surgery, Vascular Division, Medical School, National & Kapodistrian University of Athens, Laiko General Hospital
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17 Ag.Thoma St, 11527 Athens, Greece
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Tel: 2107456243, email: [email protected]
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Funding: No funding was received
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Conflict of interest: No conflict of interest to disclose
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ACCEPTED MANUSCRIPT Neoaortoiliac System procedure to treat infected aortic grafts
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Abstract
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Objective: The aim of this case series is to report the results of our centre in the surgical
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treatment of infected abdominal aortic grafts using the neo-aortoiliac system (NAIS) procedure.
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Patients and Methods: Four male and two female patients underwent a NAIS repair after
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endovascular (n=3), open (n=2) or combined surgery (n=1) in our centre. Mean age was 73±5.2
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years. Graft infection was diagnosed by computed tomography angiography (CTA) and only in
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two cases further imaging was necessary. The diagnosis was set at average 6.2 years after the
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initial procedure.
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Results: Four patients underwent a standard pantaloon NAIS procedure, one patient with a
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small aortic diameter received one femoral vein as aorto-aortic interposition graft and one
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patient received a unilateral aorto-iliac by-pass; all patients received autologous femoral veins
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grafts. Thirty-day mortality was zero, with in-hospital mortality of one patient (16.7%). Mean
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hospital stay was 27±4.9 days, with mean ICU stay of 2.2 days (range 1-3). During follow-up
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(mean 6.17 months, range 1-24 months), two patients presented with thigh wound
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complications, one of which required surgical revision. One patient was re-admitted due to
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upper gastrointestinal (GI) bleeding as a side effect of anticoagulation, without the presence of
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ulcer or other GI pathology.
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Conclusion: In our early experience NAIS showed to be a demanding procedure for both the
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patient and the surgical team. It avoids however the disadvantages of extra-anatomic by-pass
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and other methods used to treat aortic graft infection. Larger study groups are necessary to
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support these findings.
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ACCEPTED MANUSCRIPT Neoaortoiliac System procedure to treat infected aortic grafts
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Introduction
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The use of various types of synthetic grafts is nowadays common for both open (OAR) and
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endovascular (EVAR) repair of aortic aneurysms in emergency or elective cases. (1-3)
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Complications of the use of synthetic grafts in either OAR or in EVAR are increasingly
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reported and one of the most morbid and complex complications is graft infection. (3) With a
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reported incidence of 0.2-6%, graft infection is a rather uncommon complication, and therefore
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not well studied. (3, 4)
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Treatment plan for graft infection includes medical treatment with antibiotics, graft removal,
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infectious loci debridement and consequently revascularization of the lower limbs. Some
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authors suggest alternatively a more conservative management with preservation of the infected
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graft and antibiotic irrigation (5). If graft removal is decided, revascularization of the lower
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limbs can be achieved with different methods, including ligation of the aorta and extra-
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anatomic by-pass, in-situ use of cryo-preserved aortic allograft or antiobiotic-soaked prosthetic
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grafts, or neoaortoiliac system (NAIS) reconstruction using the femoral veins (FVs) of the
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patient. The latter method was first described by Clagett et al in 1993 (6) . In this publication,
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our centre’s experience with the NAIS procedure to treat aortic graft infection is described.
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Materials and methods
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This study included all patients that underwent a NAIS procedure within the period January
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2015-December 2016 in our institution. Before January 2015, aortic graft infections were
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treated with infrarenal aortic ligation and extra-anatomic axillo-bifemoral-bypass graft.
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Indications for the NAIS procedure included the presence of an infected aortic graft after
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previous open or endovascular aortic reconstruction for abdominal aortic aneurysm (AAA) or
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aortoiliac occlusive disease. All patients had received antibiotic treatment for a period of time
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in our or other institutions before surgical treatment was considered. Surgical treatment was
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considered only after failure of medical treatment.
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The diagnosis of graft infection was based on clinical and laboratory status of the patients along
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with imaging findings in CT-Angiography (CTA) and Fluorodeoxyglucose (FDG)-positron
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emission tomography (PET). Endoscopy was not part of the pre-operative diagnostic strategy,
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but performed only in cases of patients presenting with upper or lower GI bleeding. Endoscopy
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examination in these patients consisted of esophagogastroduodenoscopy as the first step,
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followed by lower GI flexible endoscopy.
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Physical status of the patients was assessed by an anesthesiologist of our hospital. All patients
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had a thorough preoperative work-up including echocardiography and lung function tests
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before proceeding with the operation. Frail patients were excluded. Anatomical criteria were
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also considered before proceeding with planning of the operation. Patients with inadequate
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cumulative length or small caliber (<11mm in females, <12mm in males) (7) FVs were
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excluded from undergoing a NAIS procedure. Therefore all patients underwent ultrasound
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study of FVs before a definite decision for NAIS was taken.
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Patients who did not meet the physical and anatomical criteria for a NAIS procedure were
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planned for an extra-anatomical bypass. Patients that were initially considered suitable to
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undergo a NAIS procedure, but intraoperative findings prevented a NAIS reconstruction,
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received also an extra-anatomical bypassIn this case, the decision was made intraoperatively by
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the chief vascular surgeon.
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The procedure was initiated with a median laparotomy in a standard fashion. The sub-
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diaphragmatic aorta was always exposed to achieve proximal control if needed. Subsequently
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the abdominal aorta and iliac arteries were exposed and the aortic graft explanted. Total
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resection of the infected graft was always planned. Partial graft excision was avoided, in an
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attempt to eradicate any possible source of persisting/recurrent infection.
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If the quality of the remaining aortic neck after graft explantation was considered acceptable for
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a NAIS reconstruction, the superficial femoral veins were thereafter removed. In case of a
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scheduled bilateral iliac reconstruction the two femoral veins were prepared and sewn in a
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pantaloon configuration.
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Whenever a deficit in the duodenal wall was identified it was always hand-sewn primarily, with
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a double-layer, single stitches, vicryl 3-0 internal layer, PDS 3-0 external layer technique. An
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omental flap was then created and secured above the duodenal closure. A Penrose drain was
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always left in proximity with the duodenal reconstruction. Drains were also always left in the
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femoral wounds.
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Postoperatively the nasogastric tube (NGT) was kept in place for 5-7 days. Upper
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gastrointestinal tract (GI) series were not regularly performed before the NGT’s removal. All
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patients received anticoagulation with daily subcutaneous injection of low molecular weight
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heparin (LMWH) and proton pump inhibitors for 1 month. All patients underwent targeted
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antibiotic treatment for up to six weeks. The respective antibiotic regime for each patient was
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decided by a multi-disciplinary team consisting of the vascular unit specialists and
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infectiologists.
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Follow-up regime consists of CTA on 1st, 6th, and 12th postoperative month, and yearly
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thereafter. Blood cultures, C-reactive protein and total blood counts are repeated weekly for the
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first month after discharge, and then repeated along the imaging protocol for the first
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postoperative
year
if
considered
necessary.
115 Results
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During the study period a total of seven patients were treated for aortic graft infection. In one
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patient, aortic ligation with axillo-bi-femoral bypass was performed because the posterior wall
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of the remaining aortic neck after explantation of the graft was judged of poor quality for a safe
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NAIS procedure. Therefore, 6 patients (four male, mean age 73±5.2 years) were treated with
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the NAIS procedure and are described below. Patients’ demographics are shown in Table 1.
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Three patients had undergone an EVAR, one patient an open AAA repair, and one patient had
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an aortic tube graft for aortic stenosis. The remaining patient had a complex past surgical
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history of initial open AAA repair and a consequent aorto-monoiliac endovascular repair with a
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femoro-femoral by-pass due to a proximal para-anastomotic aneurysm 5 years after the primary
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procedure. Five patients presented with fever and poor general status. Two patients presented
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with GI bleeding; one patient had no findings in endoscopy and one had thrombus in the third
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segment of the duodenum. Lower GI endoscopy was negative for both these patients. Previous
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blood cultures performed before referral were positive for Streptococcus mitis (1 patient),
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Methicillin-resistant Staphylococcus aureus or MRSA (2 patients) and Staphylococcus
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epidermidis (2 patients). One patient had never had positive blood cultures. All patients had
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received long-term antibiotic treatment and had negative blood cultures before being referred to
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our department. Despite proper antibiotic treatment, one patient had a positive blood culture
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for MRSA during his hospitalization in our department. All patients presented with
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leukocytosis and elevated serum C-reactive protein levels.
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The diagnosis of graft infection wasset at average 6.2 years (range 9 months-15 years) after the
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initial graft implantation. Findings in CT scan included peri-graft gas, thickening of the peri-
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ACCEPTED MANUSCRIPT graft tissues and in three cases an adherence of the duodenum to the graft. (Fig 1.)
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Fluorodeoxyglucose (FDG)-positron emission tomography (PET) was utilized by the referring
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physicians for proper diagnosis in two cases; in one case to exclude other possible infection
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sites, and in another case to ensure that the femoro-femoral by-pass graft of the patient is not
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infected.
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Four patients underwent pantaloon NAIS with the use of both FVs. One patient with previous
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tubing of a very small aorta treated for stenosis received one FV as aorto-aortic interposition
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graft. One patient underwent a unilateral NAIS procedure to the right common iliac artery
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(CIA) while a previously implanted femoro-femoral by-pass was still patent, without signs of
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infection. In one case a duodenal exclusion with a concomitant gastrojejunal anastomosis was
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performed due to unfavorable local conditions. Mean procedure time was 510 ± 65 minutes.
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Thirty-day mortality was zero, with in-hospital mortality of one patient (16.7%). This patient
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died on the 37th postoperative day due to complications from severe cholangiitis and
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overwhelming sepsis. Two patients developed thigh wound complications, one required
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surgical revision. Mean ICU stay was 2.2 days (range 1-3) and mean hospital stay was 27±4.9
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days (range 19-34 days). Graft material cultures were positive for S. epidermidis in two patients
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and for MRSA in one, while the rest had negative graft material cultures. During follow-up
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(mean 6.17 months, range 1-24 months) one patient was re-admitted due to upper
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gastrointestinal (GI) bleeding as a side effect of anticoagulation, without the presence of ulcer
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or other GI pathology.
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Discussion
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Aortic graft infection following infrarenal aortic reconstruction is (8) one of the most morbid
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complications in vascular surgery (8). Management of infected aortic grafts ranges from more
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conservative options (systemic antibiotic treatment, local antibiotic or antiseptic lavage,
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The use of stent grafts mainly as a "bridging" option in high-risk patients with delayed
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definitive surgical management is also reported. (9-12).
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Upon excision of the infected graft, revascularisation is achieved in anatomic or extra-anatomic
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fashion using an autologous graft, a cryopreserved allograft, or a synthetic graft. (13) Extra-
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anatomic revascularization after aortic ligation is associated with a risk for aortic stump
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blowout, and suboptimal long-term patency. Additionally the use of a synthetic extra-anatomic
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by-pass graft can lead to an increased rate of infection recurrence. In situ anatomic
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revascularisation with a new synthetic graft (either bare or antibiotic-soaked) often leads to
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recurrent infection. Cryopreserved allografts can be alternatively used for anatomic
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revascularization, but these grafts are not available in all centers including ours. (3). (13). (14,
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15)
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In 1993, Clagett et al. described the NAIS as the aortic reconstruction method to be used after
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aortic graft infection and graft excision, an idea based on the work of Schulman et al., who first
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used the FV as a conduit for femoro-popliteal by-pass. (6) The procedure of FV harvesting has
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been reported in great detail, as well as potential tricks and pitfalls of the procedure, and it
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consists of in situ reconstruction of the aorta using the FVs of the patient. (6, 16-18) In those
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cases where both FVs are of proper size and both excised, the result of this method is a
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reinfection-resistant neo-aorta of similar caliber to the original aorta. In patients with FVs of
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inadequate length (<30cm) or diameter, one FV can be used to by-pass the aortic flow to one
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common iliac artery along with another by-pass utilizing either the shorter FV, the great
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saphenous vein or a synthetic conduit for the contralateral limb. (19) FVs or FVs of patients,
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who have undergone CABG or other revascularization procedures, might not be available for
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harvesting. Severe femoro-popliteal arterial diseases and previously performed saphenectomy
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may be relative contraindications for NAIS. It is obvious that careful and detailed preoperative
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Clearly not all patients presenting with aortic graft infection are suitable for the NAIS
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procedure. The overall clinical status of the patient should be carefully evaluated preoperatively
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including detailed assessment of the cardiorespiratory capacity as previously described. A
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thorough imaging and laboratory work-up is also of significant importance in order to securely
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establish the diagnosis of graft infection, before jumping quickly to a highly morbid procedure
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as the NAIS. The NAIS procedure was undertaken only after diagnosis of graft infection and
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approval of the vascular anesthesiology team regarding the physical status of the patient.
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In poor surgical candidates a more conservative approach can be considered, such as
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percutaneous peri-aortic drainage, graft lavage, or omental flap. Reported results show that
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these methods do have a place in current aortic graft treatment, although they should be
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generally considered for frail patients who cannot undergo intensive and demanding surgery.
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(20) Although successful treatment of aortic graft by the above-described less invasive methods
201
is reported as single cases in literature (21-25), the main disadvantage of these methods is the
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inability to eradicate the infection completely, which is linked to high complication and
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morbidity rates. (20) Additionally, graft preservation is not a choice of treatment in cases with
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an AEF present or in grafts infected with Gram-negative species. (26) On the other hand
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surgical treatment for aortic graft infection is also linked to substantial complication and
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morbidity rates that differ between various approaches. (27) Further research is necessary to
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establish when minimally invasive or conservative treatment for aortic graft infection is safe
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and efficient, as existing data is both limited and contradicting. (8, 26, 28)
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Every effort should be also undertaken, pre-operatively, intra-operatively and post-operatively
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for identification of the cause of the infection, given the different treatment regimen and
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prognosis according to each infecting agent. In our series preoperative identification of the
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ACCEPTED MANUSCRIPT infecting agent was not always possible, something that is already reported as a common
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finding in literature. (29) Bacteria identified in our cases were also in line with already
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published findings. (29, 30) S. epidermidis is considered a low virulence micro-organism, while
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the presence of S. aureus or MRSA is a significant risk factor for the patient; all three bacteria
216
were found in some of the patients in this series. (30) Streptococcus mitis is a Gram-positive
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coccus, facultative anaerobe and catalase negative micro-organism, part of the natural human
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microbiota, which has been rarely reported as a microbial agent in aortic graft infection. (31)
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In most case series, early and 5-year mortality is reported to be in the range of 10% and 50%
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respectively. (13, 18, 32) Long-term patency after NAIS is reported to be higher than any other
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modality, reaching primary patency rate higher than 86% at 5 years, and a cumulative
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secondary patency rate as high as 100%. (4, 18, 33-35). Early patency in our cases is 100%
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but as the mean follow-up period is 6 months long-term patency cannot be reported yet.
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Although complications related to aortic-ligation and extra-anatomical bypasses might be
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avoided, NAIS carries its own related complications. Complications related to the thigh
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incisions include haemorrhage, infection, and dehiscence. (4, 32) Two of our patients had thigh
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wound-related complications, one of which required surgical revision. Complications also arise
228
from inadequate venous return, presenting with usually temporary limb edema but in rare cases
229
with compartment syndrome. (4, 32) In our cases, light to mediate edema was present in three
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limbs, but it has resolved spontaneously without any need for additional interventions. Another
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method-related complication is graft stenosis, with a reported prevalence varying from 4.6% to
232
as high as 23.5%. (4, 13, 34, 36) Graft stenosis is more common when FVs of small diameter
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are used to re-establish aorto-iliac continuity, in smokers and in patients with coronary artery
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disease. Aneurysmal degeneration of the FV may also be a concern in the long-term. These
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patients should therefore undergo vigorous follow-up. A scheduled surveillance protocol,
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Furthermore a long-lasting antibiotic therapy may be considered. (19)
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NAIS remains a demanding procedure for both the patient and the vascular team. The
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procedure time is usually long, but the simultaneous work of a second surgical team can
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potentially reduce it by two hours. (18, 33) Staging of the NAIS procedure, with FVs harvested
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one day earlier than the revascularization procedure is also reported.(33) Both these tactics
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however, run the risk of harvesting the FVs without finally being used, in case of poor aortic
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neck wall quality that precludes a NAIS procedure. In our centre, the aorta is first exposed and
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the infected graft removed, and if the remaining aortic wall is judged of adequate quality for an
245
anastomosis, then FV harvesting is performed by the same surgical team.
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Despite the existing unsolved questions whether conservative, minimally invasive or surgical
247
treatment is best for treating aortic graft infections, our team considers NAIS to be an attractive
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solution to this grave complication of aortic surgery when patients are carefully selected; a
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common consideration that exists in many centres. (27)
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Conclusion
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Our preliminary experience with the NAIS procedure seems encouraging. The operation is
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technically demanding, but once successful it offers complete eradication of the infection,
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without compromising lower-extremity perfusion. An intensive tracking of peri-operative and
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long-term follow-up results is warranted, in order to establish the role of this technique as
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standard of practice, at least in selected high-volume vascular centers.
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References: 1. Steuer J, Lachat M, Veith FJ, Wanhainen A. Endovascular grafts for abdominal aortic aneurysm. Eur Heart J. 2016;37(2):145-51. 2. Patelis N, Moris D, Karaolanis G, Georgopoulos S. Endovascular vs. Open Repair for Ruptured Abdominal Aortic Aneurysm. Medical science monitor basic research. 2016;22:34-44. 3. Smeds MR, Duncan AA, Harlander-Locke MP, Lawrence PF, Lyden S, Fatima J, et al. Treatment and outcomes of aortic endograft infection. J Vasc Surg. 2016;63(2):332-40. 4. Kilic A, Arnaoutakis DJ, Reifsnyder T, Black JH, 3rd, Abularrage CJ, Perler BA, et al. Management of infected vascular grafts. Vascular medicine. 2016;21(1):53-60. 5. Akhtar M, Meecham L, Birkett R, Pherwani AD, Fairhead JF. Conservative Treatment of an Infected Aortic Graft with Antibiotic Irrigation. Int J Angiol. 2016;25(5):e118-e20. 6. Clagett GP, Bowers BL, Lopez-Viego MA, Rossi MB, Valentine RJ, Myers SI, et al. Creation of a neo-aortoiliac system from lower extremity deep and superficial veins. Ann Surg. 1993;218(3):239-48; discussion 48-9. 7. Fronek A, Criqui MH, Denenberg J, Langer RD. Common femoral vein dimensions and hemodynamics including Valsalva response as a function of sex, age, and ethnicity in a population study. J Vasc Surg. 2001;33(5):1050-6. 8. Debus ES, Diener H. Reconstructions Following Graft Infection: An Unsolved Challenge. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2016. 9. Carrel T, Schmidli J. Management of vascular graft and endoprosthetic infection of the thoracic and thoraco-abdominal aorta. Multimed Man Cardiothorac Surg. 2011;2011(1101):mmcts 2010 004705. 10. Kotsis T, Lioupis C, Tzanis A, Nasiopoulou P, Goumas K, Bakoyiannis K, et al. Endovascular repair of a bleeding secondary aortoenteric fistula with acute leg ischemia: a case report and review of the literature. Journal of vascular and interventional radiology : JVIR. 2006;17(3):563-7. 11. Lonn L, Dias N, Veith Schroeder T, Resch T. Is EVAR the treatment of choice for aortoenteric fistula? J Cardiovasc Surg (Torino). 2010;51(3):319-27. 12. Verma H, Mohan S, Tripathi RK. Pantaloon femoral vein graft as "neoaorta" in infected aortic disease. J Vasc Surg. 2015;62(4):1083-8. 13. Ali AT, Modrall JG, 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(1):30-9. 14. Kahlberg A, Melissano G, Tshomba Y, Leopardi M, Chiesa R. Strategies to treat thoracic aortitis and infected aortic grafts. J Cardiovasc Surg (Torino). 2015;56(2):269-80. 15. Goeau-Brissonniere O, Leport C, Guidoin R, Lebrault C, Pechere JC, Bacourt F. Experimental colonization of an expanded polytetrafluoroethylene vascular graft with Staphylococcus aureus: a quantitative and morphologic study. J Vasc Surg. 1987;5(5):743-8. 16. Smith ST, Clagett GP. Femoral vein harvest for vascular reconstructions: pitfalls and tips for success. Seminars in vascular surgery. 2008;21(1):35-40. 17. Valentine RJ. Harvesting the superficial femoral vein as an autograft. Seminars in vascular surgery. 2000;13(1):27-31.
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18. Chung J, Clagett GP. Neoaortoiliac System (NAIS) procedure for the treatment of the infected aortic graft. Seminars in vascular surgery. 2011;24(4):220-6. 19. Lopera JE, Trimmer CK, Josephs S, Dolmatch B, Valentine RJ, Clagett GP. Neoaortoiliac reconstructions using femoropopliteal veins: MDCT angiography findings. AJR American journal of roentgenology. 2008;191(2):569-77. 20. Igari K, Kudo T, Toyofuku T, Jibiki M, Sugano N, Inoue Y. Treatment strategies for aortic and peripheral prosthetic graft infection. Surgery today. 2014;44(3):466-71. 21. Hulin SJ, Morris GE. Aortic endograft infection: open surgical management with endograft preservation. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2007;34(2):191-3. 22. Mo A, Lin H. Successful therapy for a patient with aortic graft infection without graft removal. Annals of vascular surgery. 2011;25(5):698 e1-4. 23. Gordon A, Conlon C, Collin J, Peto T, Gray D, Hands L, et al. An eight year experience of conservative management for aortic graft sepsis. Eur J Vasc Surg. 1994;8(5):611-6. 24. Morris GE, Friend PJ, Vassallo DJ, Farrington M, Leapman S, Quick CR. Antibiotic irrigation and conservative surgery for major aortic graft infection. J Vasc Surg. 1994;20(1):88-95. 25. Quick CR, Vassallo DJ, Colin JF, Heddle RM. Conservative treatment of major aortic graft infection. Eur J Vasc Surg. 1990;4(1):63-7. 26. Lawrence PF. Conservative treatment of aortic graft infection. Seminars in vascular surgery. 2011;24(4):199-204. 27. Heinola I, Kantonen I, Jaroma M, Alback A, Vikatmaa P, Aho P, et al. Editor's Choice - Treatment of Aortic Prosthesis Infections by Graft Removal and In Situ Replacement with Autologous Femoral Veins and Fascial Strengthening. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2016;51(2):232-9. 28. Ohta T, Hosaka M, Ishibashi H, Sugimoto I, Takeuchi N, Kazui H, et al. Treatment for aortic graft infection. Surgery today. 2001;31(1):18-26. 29. FitzGerald SF, Kelly C, Humphreys H. Diagnosis and treatment of prosthetic aortic graft infections: confusion and inconsistency in the absence of evidence or consensus. J Antimicrob Chemother. 2005;56(6):996-9. 30. Hodgkiss-Harlow KD, Bandyk DF. Antibiotic therapy of aortic graft infection: treatment and prevention recommendations. Seminars in vascular surgery. 2011;24(4):191-8. 31. Leseche G, Castier Y, Petit MD, Bertrand P, Kitzis M, Mussot S, et al. Long-term results of cryopreserved arterial allograft reconstruction in infected prosthetic grafts and mycotic aneurysms of the abdominal aorta. J Vasc Surg. 2001;34(4):616-22. 32. Budtz-Lilly J, Eldrup N, Vammen S, Laustsen J. Femoral vein repair of arterial infections: technical tips to reduce procedure time. Vasc Endovascular Surg. 2014;48(5-6):367-71. 33. Ali AT, McLeod N, Kalapatapu VR, Moursi MM, Eidt JF. Staging the neoaortoiliac system: feasibility and short-term outcomes. J Vasc Surg. 2008;48(5):1125-30; discussion 30-1.
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34. Beck AW, Murphy EH, Hocking JA, Timaran CH, Arko FR, Clagett GP. Aortic reconstruction with femoral-popliteal vein: graft stenosis incidence, risk and reintervention. J Vasc Surg. 2008;47(1):36-43; discussion 4. 35. Modrall JG, Sadjadi J, Joiner DR, Ali A, Welborn MB, 3rd, Jackson MR, et al. Comparison of superficial femoral vein and saphenous vein as conduits for mesenteric arterial bypass. J Vasc Surg. 2003;37(2):362-6. 36. Faulk J, Dattilo JB, Guzman RJ, Naslund TC, Passman MA. Neoaortic reconstruction for aortic graft infection: need for endovascular adjunctive therapies? Annals of vascular surgery. 2005;19(6):774-81.
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Table I: Patients’ demographics and data. Gender
Age
Present ing Sympto ms
Comorbidities
Initial Operation
Timeframe since 1st repair
Procedure
Pantaloon NAIS with FVs;
F
80
Fever, poor status
Hypertension, dyslipidemia
EVAR
2 years
2
M
75
CABG, hypertension
EVAR
9 months
3
M
76
Poor status, low grade fever GI bleedin g Fever, lower GI bleedin g
Partial gastrectomy, hypertension, AF
Open AAA repair; Aortomonoiliac EVAR for paraanastomotic aneurysm and femoro-femoral bypass 5 yrs later
M AN U
SC
1
Pantaloon NAIS with FVs;
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14 years
Complications
Reintervention
Thigh hematoma
Hematoma drainage
Bilateral thigh wounds dehiscence
No
In-hospital death due to acute cholangiitis
-
RI PT
Pt
NAIS to right CIA with FV (previous femorofemoral bypass patent)
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F
65
Poor status, low grade fever
Hypertension, dyslipidemia
Aortic tubing for aortic stenosis
15 years
One FV as Aorto-aortic interposition graft
5
M
70
Fever
CABG, hypertension
Open AAA repair
2 years
Pantaloon NAIS with FVs
6
M
72
Low grade Fever
hypertension, DM
EVAR
3 years
Pantaloon NAIS with FVs
Upper GI bleeding due to anticoagulation
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RI PT
4
No
-
No
-
No
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EVAR – endovascular aneurysm repair; CABG – coronary artery bypass graft; FV – femoral vein; CIA – common iliac artery; AF – atrial fibrillation; NAIS – neoaortoiliac system; DM – diabetes mellitus; GI- gastrointestinal; AAA –abdominal aortic aneurysm
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