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Replacement of Infected Prosthetic Femoral Graft with Longitudinally Tailored Vein Patches
EJVES Extra 23 (2012) e40ee41
Contents lists available at SciVerse ScienceDirect
EJVES Extra journal homepage: www.ejvesextra.com
Short Report
Replacement of Infected Prosthetic Femoral Graft with Longitudinally Tailored Vein Patches A. Mallios*, B. Boura, W. Yankovic, A. Costanzo, M. Combes Department of Vascular Surgery, Institut Mutualiste Montsouris (IMM), 42 Boulevard Jourdan, 75674 Paris, France
a r t i c l e i n f o
a b s t r a c t
Article history: Received 26 December 2011 Accepted 15 February 2012
Infection of prosthetic material is a devastating complication in vascular surgery, often resulting in death or amputation. We present the case of a 55-year-old man operated for aortic valve replacement and at the same time aneurysm resection of the right femoral artery and replacement with a termino-terminal 10 mm Dacron graft. On the 14th postoperative day, the patient presented local and systemic inflammatory signs with positive blood cultures for Staphylococcus epidermidis. Replacement of the graft with autogenous material was judged mandatory but technically challenging due to the large calibre of the artery and, on the other hand, small diameter of the saphenous vein. A composite vein graft was tailored in a technically interesting way. The postoperative course was uneventful and the graft remained patent. Prosthesis infection is a challenging situation often complicated by the lack of autogenous material. The method presented is a feasible alternative and to our knowledge it is the first time such a technique is described for the replacement of an infected prosthesis. Ó 2012 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Prosthetic graft infection Composite autogenous graft
Introduction Prosthetic graft infection is one of the most challenging situations in vascular surgery. It often manifests with acute bleeding due to rupture of anastomosis. Tissues are more fragile and more difficult to recognise. Suitable autogenous material must be used if possible to control the infection and restore circulation. In the case of total graft excision, amputation rates range from 9% to 52%, while mortality reaches 9e36%.1,2 Various strategies have been reported for the treatment of prosthetic graft infection. Total excision with extra-anatomic bypass, partial excision, use of the femoro-popliteal vein, muscle flaps and cryopreserved allografts are just a few of them.3,4 We report the case of a patient that we have treated for an infected Dacron prosthesis of the right groin. Autogenous material of sufficient calibre was not available; hence, we tailored an autogenous venous graft with three longitudinally opened segments of the long saphenous vein. To our knowledge, there is only one similar but not identical report for the aortoiliac region.5
aortic valve replacement and simultaneous resection of a femoral artery aneurysm and replacement with a 10-mm Dacron prosthesis. On day 14 postoperatively, the patient presented local and systemic inflammatory signs with positive cultures to Staphylococcus epidermidis. Due to the recent aortic valve surgery, we considered that there was an important risk of endocarditis and an urgent, radical solution was indicated. Due to the large calibre of the prosthesis and the lack of suitable autologous material, we had to tailor a composite venous graft. The infected 10-mm diameter Dacron graft was dissected without particular problems and proximal and distal control was obtained. The long saphenous vein was harvested to a length approximately 3 times the length of the infected graft about to be replaced. The vein was cut into three segments that were opened longitudinally to create three equal patches. The first patch was tailored proximally on the external iliac artery and distally on the femoral bifurcation, to form the posterior wall of the graft (Fig. 1). The second patch formed the antero-medial part of the graft. Finally, the third patch was tailored forming the antero-lateral part and completing a composite tube (Fig. 2).
Case Report e Technique We present the case of a 55-year-old obese male patient with an infected Dacron prosthesis of the right groin. The patient had an DOI of original article: 10.1016/j.ejvs.2012.02.028. * Corresponding author. Tel.: þ33 621265747. E-mail address: [email protected] (A. Mallios).
Discussion Graft infections represent one of the most challenging situations in vascular surgery. Total resection of the graft is related with significant thigh ischaemia responsible for high amputation and mortality rates.1 Ehsan reported the use of the femoro-popliteal
1533-3167/$ e see front matter Ó 2012 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ejvsextra.2012.02.006
A. Mallios et al. / EJVES Extra 23 (2012) e40ee41
Figure 1. Replacement of the Dacron graft with a composite venous graft. Image after suturing the first venous patch forming the posterior wall of the graft.
e41
complex and require a long time of open wound care. Of course, recurrence in the long term cannot be excluded.1,4 In the case of our patient, due to the risk of endocarditis, we considered essential a radical treatment of the infection and the most safe method for that was the replacement with autologous material. Geroulakos et al.5 reported the use of the long saphenous vein opened longitudinally and tailored side by side to create a wider calibre autologous graft for the treatment of an iliac aneurysm in the context of a potentially contaminated operation in the region. Although the principle of this report is the same, there are some essential differences. In our patient, the goal was the treatment of an existing infection and not prevention. The graft was tailored in place and not prepared and sutured afterwards, as in the case of Geroulakos’ report. Furthermore, with the reported technique, any vein even of small calibre found intra-operatively can be suitable. This is the main advantage as tailoring the patches longitudinally and adding as many as required (more than three if needed) gives the operator the ability to create a large composite tube. The main limitation of this technique is the length of the infected graft that needs to be replaced. Given the fact that the length of the saphenous vein needs to be double or triple the length (or even more depending on the number of patches that need to be used e defined by the difference of calibre between the graft and saphenous vein), very long replacements may not be possible with this technique. Conclusion This is the first report of replacement of an infected prosthetic graft by means of a composite venous graft tailored longitudinally. This technique has probably some length limitations but can be a feasible alternative in some situations.
Figure 2. Final image after the release of the arterial flow in the composite venous graft.
vein for the replacement of infected grafts. Results were encouraging; however, as expected, some problems with limb swelling did occur.2 In the context of our patient with recent heart surgery and obesity, we preferred not to expose him to greater risks entailed with a longer incision and extensive thigh dissection and to restrict the operation at the groin area as long as an autologous graft was feasible. Cryopreserved allografts are an attractive alternative. Results were satisfactory; however, restricted availability, the procedure of preservation and the related costs would not permit a worldwide application.3 Reports of successful treatment of infection with graft preservation do exist; nevertheless, all these procedures are quite
Conflict of Interest/Funding None. References 1 Calligaro K, Veith F, Gupta S, Ascer E, Dietzek A, Franco C, et al. A modified method for management of prosthetic graft infections involving an anastomosis to the common femoral artery. J Vasc Surg 1990;11:485e92. 2 Ehsan O, Gibbons CP. A 10-year experience of using femoro-popilteal vein for revascularisation in graft and arterial infections. Eur J Vasc Endovasc Surg 2009;38:172e9. 3 Gabriel M, Pukacki F, Dzieciuchowicz L, Oszkinis G, Checinski P. Cryopreserved arterial allografts in the treatment of prosthetic graft infections. Eur J Vasc Edovasc Surg 2004;27:590e6. 4 Armstrong P, Back M, Bandyk D, Johnson B, Shames M. Selective application of sartorius flaps and aggressive staged surgical debridement can influence longterm outcomes of complex prosthetic graft infections. J Vasc Surg 2007;46:71e8. 5 Geroulakos G, Kakkos SK, Sellu D. Autologous fashioned graft for aneurysm repair in a contaminated field. Eur J Vasv Endovas Surg 2005;29:247e9.
Contents lists available at SciVerse ScienceDirect
EJVES Extra journal homepage: www.ejvesextra.com
Short Report
Replacement of Infected Prosthetic Femoral Graft with Longitudinally Tailored Vein Patches A. Mallios*, B. Boura, W. Yankovic, A. Costanzo, M. Combes Department of Vascular Surgery, Institut Mutualiste Montsouris (IMM), 42 Boulevard Jourdan, 75674 Paris, France
a r t i c l e i n f o
a b s t r a c t
Article history: Received 26 December 2011 Accepted 15 February 2012
Infection of prosthetic material is a devastating complication in vascular surgery, often resulting in death or amputation. We present the case of a 55-year-old man operated for aortic valve replacement and at the same time aneurysm resection of the right femoral artery and replacement with a termino-terminal 10 mm Dacron graft. On the 14th postoperative day, the patient presented local and systemic inflammatory signs with positive blood cultures for Staphylococcus epidermidis. Replacement of the graft with autogenous material was judged mandatory but technically challenging due to the large calibre of the artery and, on the other hand, small diameter of the saphenous vein. A composite vein graft was tailored in a technically interesting way. The postoperative course was uneventful and the graft remained patent. Prosthesis infection is a challenging situation often complicated by the lack of autogenous material. The method presented is a feasible alternative and to our knowledge it is the first time such a technique is described for the replacement of an infected prosthesis. Ó 2012 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Prosthetic graft infection Composite autogenous graft
Introduction Prosthetic graft infection is one of the most challenging situations in vascular surgery. It often manifests with acute bleeding due to rupture of anastomosis. Tissues are more fragile and more difficult to recognise. Suitable autogenous material must be used if possible to control the infection and restore circulation. In the case of total graft excision, amputation rates range from 9% to 52%, while mortality reaches 9e36%.1,2 Various strategies have been reported for the treatment of prosthetic graft infection. Total excision with extra-anatomic bypass, partial excision, use of the femoro-popliteal vein, muscle flaps and cryopreserved allografts are just a few of them.3,4 We report the case of a patient that we have treated for an infected Dacron prosthesis of the right groin. Autogenous material of sufficient calibre was not available; hence, we tailored an autogenous venous graft with three longitudinally opened segments of the long saphenous vein. To our knowledge, there is only one similar but not identical report for the aortoiliac region.5
aortic valve replacement and simultaneous resection of a femoral artery aneurysm and replacement with a 10-mm Dacron prosthesis. On day 14 postoperatively, the patient presented local and systemic inflammatory signs with positive cultures to Staphylococcus epidermidis. Due to the recent aortic valve surgery, we considered that there was an important risk of endocarditis and an urgent, radical solution was indicated. Due to the large calibre of the prosthesis and the lack of suitable autologous material, we had to tailor a composite venous graft. The infected 10-mm diameter Dacron graft was dissected without particular problems and proximal and distal control was obtained. The long saphenous vein was harvested to a length approximately 3 times the length of the infected graft about to be replaced. The vein was cut into three segments that were opened longitudinally to create three equal patches. The first patch was tailored proximally on the external iliac artery and distally on the femoral bifurcation, to form the posterior wall of the graft (Fig. 1). The second patch formed the antero-medial part of the graft. Finally, the third patch was tailored forming the antero-lateral part and completing a composite tube (Fig. 2).
Case Report e Technique We present the case of a 55-year-old obese male patient with an infected Dacron prosthesis of the right groin. The patient had an DOI of original article: 10.1016/j.ejvs.2012.02.028. * Corresponding author. Tel.: þ33 621265747. E-mail address: [email protected] (A. Mallios).
Discussion Graft infections represent one of the most challenging situations in vascular surgery. Total resection of the graft is related with significant thigh ischaemia responsible for high amputation and mortality rates.1 Ehsan reported the use of the femoro-popliteal
1533-3167/$ e see front matter Ó 2012 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ejvsextra.2012.02.006
A. Mallios et al. / EJVES Extra 23 (2012) e40ee41
Figure 1. Replacement of the Dacron graft with a composite venous graft. Image after suturing the first venous patch forming the posterior wall of the graft.
e41
complex and require a long time of open wound care. Of course, recurrence in the long term cannot be excluded.1,4 In the case of our patient, due to the risk of endocarditis, we considered essential a radical treatment of the infection and the most safe method for that was the replacement with autologous material. Geroulakos et al.5 reported the use of the long saphenous vein opened longitudinally and tailored side by side to create a wider calibre autologous graft for the treatment of an iliac aneurysm in the context of a potentially contaminated operation in the region. Although the principle of this report is the same, there are some essential differences. In our patient, the goal was the treatment of an existing infection and not prevention. The graft was tailored in place and not prepared and sutured afterwards, as in the case of Geroulakos’ report. Furthermore, with the reported technique, any vein even of small calibre found intra-operatively can be suitable. This is the main advantage as tailoring the patches longitudinally and adding as many as required (more than three if needed) gives the operator the ability to create a large composite tube. The main limitation of this technique is the length of the infected graft that needs to be replaced. Given the fact that the length of the saphenous vein needs to be double or triple the length (or even more depending on the number of patches that need to be used e defined by the difference of calibre between the graft and saphenous vein), very long replacements may not be possible with this technique. Conclusion This is the first report of replacement of an infected prosthetic graft by means of a composite venous graft tailored longitudinally. This technique has probably some length limitations but can be a feasible alternative in some situations.
Figure 2. Final image after the release of the arterial flow in the composite venous graft.
vein for the replacement of infected grafts. Results were encouraging; however, as expected, some problems with limb swelling did occur.2 In the context of our patient with recent heart surgery and obesity, we preferred not to expose him to greater risks entailed with a longer incision and extensive thigh dissection and to restrict the operation at the groin area as long as an autologous graft was feasible. Cryopreserved allografts are an attractive alternative. Results were satisfactory; however, restricted availability, the procedure of preservation and the related costs would not permit a worldwide application.3 Reports of successful treatment of infection with graft preservation do exist; nevertheless, all these procedures are quite
Conflict of Interest/Funding None. References 1 Calligaro K, Veith F, Gupta S, Ascer E, Dietzek A, Franco C, et al. A modified method for management of prosthetic graft infections involving an anastomosis to the common femoral artery. J Vasc Surg 1990;11:485e92. 2 Ehsan O, Gibbons CP. A 10-year experience of using femoro-popilteal vein for revascularisation in graft and arterial infections. Eur J Vasc Endovasc Surg 2009;38:172e9. 3 Gabriel M, Pukacki F, Dzieciuchowicz L, Oszkinis G, Checinski P. Cryopreserved arterial allografts in the treatment of prosthetic graft infections. Eur J Vasc Edovasc Surg 2004;27:590e6. 4 Armstrong P, Back M, Bandyk D, Johnson B, Shames M. Selective application of sartorius flaps and aggressive staged surgical debridement can influence longterm outcomes of complex prosthetic graft infections. J Vasc Surg 2007;46:71e8. 5 Geroulakos G, Kakkos SK, Sellu D. Autologous fashioned graft for aneurysm repair in a contaminated field. Eur J Vasv Endovas Surg 2005;29:247e9.