The Efficacy of Autologous Femoropopliteal Vein Reconstruction for Primary Aortic and Aortic Graft Infection

Accepted Manuscript The efficacy of autologous femoro-popliteal vein reconstruction for primary aortic and aortic graft infection M. Dirven, M.F. van der Jagt, W.B. Barendregt, J.A. van der Vliet PII:

S0890-5096(15)00346-5

DOI:

10.1016/j.avsg.2015.03.043

Reference:

AVSG 2364

To appear in:

Annals of Vascular Surgery

Received Date: 28 December 2014 Revised Date:

17 March 2015

Accepted Date: 21 March 2015

Please cite this article as: Dirven M, van der Jagt M, Barendregt W, van der Vliet J, The efficacy of autologous femoro-popliteal vein reconstruction for primary aortic and aortic graft infection, Annals of Vascular Surgery (2015), doi: 10.1016/j.avsg.2015.03.043. 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.

ACCEPTED MANUSCRIPT The efficacy of autologous femoro-popliteal vein reconstruction for primary aortic and aortic graft infection M Dirven¹,², MF van der Jagt¹, WB Barendregt² and JA van der Vliet¹

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¹Department of Surgery, Division of Vascular and Transplant Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands

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² Department of Vascular Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands

ACCEPTED MANUSCRIPT Abstract

Introduction:

reconstruction for primary aortic- or aortic graft infection. Patients and methods:

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The objective of our study was to analyse the efficacy of autologous superficial femoro-popliteal vein

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We performed a retrospective analysis of 14 patients treated for an infected aortic prosthesis or primary infected aorta between 2012 and 2014. Three patients had a primary mycotic aneurysm

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caused by a salmonella or coxiella burnetti infection. Seven patients were treated previously for aortic aneurysms with a conventional dacron vascular prosthesis and four with an endovascular prosthesis. All infected prosthesis were explanted via median laparotomy with subsequent debridement of the aortic aneurysm wall. Aortic reconstruction was performed with one or two

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superficial femoro-popliteal veins, interpositioning the greater omentum when possible. The primary outcome measure was 30-day mortality. Secondary outcome measures were re-operation, operating time, amputation rate, length of ICU and hospital stay, re-infection rate and limb oedema requiring

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Results:

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compression therapy.

The 30-day mortality was 28%. Two patients died of an abdominal sepsis, one patient of a cerebrovascular accident and another of a hypovolemic shock. One patient died at home two years after surgery of unknown cause. Four patients required a re-operation. The median intraoperative blood loss was 1500 mL (500-8000). Median operating time was 364 minutes (264-524). Median length of ICU stay was 3,5 days (1-47) and median hospital stay was 20 days (10-47). There were no limb amputations. Mild oedema of the donor leg was documented in two patients. Compression

ACCEPTED MANUSCRIPT stockings were not worn by any patients. Postoperative antibiotic treatment was administered for at least 6 weeks. No recurrent infections were diagnosed. Conclusion:

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Autologous venous reconstruction of the aorta offers advantages over other therapeutic approaches and deserves a prominent place in the treatment of the primary infected aorta or an infected aortic

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prosthetic graft.

ACCEPTED MANUSCRIPT Introduction Primary aortic infection or aortic graft infection after aneurysm repair presents a challenge for vascular surgeons. The incidence of mycotic aneurysms is 0.7-3% in all patients with an aortic aneurysm (1). A mycotic aneurysm is more dangerous than a conventional aneurysm and will rupture

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in 60% of patients if left untreated (2). Infection of an aortic prosthesis is a potentially lethal disease and notoriously difficult to manage (figure 1). Peri-operative contamination, mechanical erosion, aortic-enteric fistulae or remote sources of haematogenous bacterial spread may be involved in its

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etiology (3). The incidence of aortic graft infection is low. It varies from 0.2-2% of patients treated for an aortic aneurysm (4,5,6). Conservative treatment with antibiotics is associated with mortality rates

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up to 46% (7). Operations such as extra-anatomical reconstruction after resection of the infected graft result in high amputation rates and mortality due to stump blow outs. Advances in management of aortic infections have improved mortality rates over the last decade(3). Surgical options now include implantation of a rifampicin soaked prosthesis, cryopreserved allografts or in

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situ autogenous vein reconstruction. The aim of the present study was to assess the efficacy of

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autologous femoro-popliteal vein reconstruction for primary aortic and aortic graft infection.

ACCEPTED MANUSCRIPT Patients and methods Study design We performed a retrospective analysis of 14 cases treated between 2012 and 2014. Medical patient

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records from the Radboud UMC and Canisius Wilhelmina hospital were analysed. The primary outcome measure was 30-day mortality. Secondary outcome measures were re-operation, operating time, amputation rate, length of ICU and hospital stay and limb oedema requiring compression

indicated otherwise.

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Patient demography and preoperative work-up

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therapy. All data in this study are presented as a median with a range between brackets unless

The age of our patients was 69 years (57-78). Ten (71%) patients were male. All patients were burdened with cardiovascular co-morbidity such as diabetes, smoking, hypertension and a previous stroke. All patients had a proven primary infection of the infrarenal aorta or an infected aortic

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prosthesis. The patients presented various clinical signs of fever, back- or abdominal pain, hematemesis and overall weakness. Elevated leukocytes or C-reactive protein and outcomes of blood and needle aspiration cultures in the presence of a para-aortic fluid collection contributed to

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determination of the diagnosis (Table I). In all patients a computed tomography scan (CT-scan) or positron emission tomography-CT scan (PET-CT scan) was performed to confirm the diagnosis (Figure

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2). Patients did not receive a PET-CT scan in emergency setting or if the diagnosis was clearly visible on CT-scan. We considered signs such as peri-aortitis, gas and fluid collections in the aneurysm sac, increased FDG-uptake, concomitant spondylodiscitis and aorto-enteric fistulae proof for an infection. Preoperative duplex scanning of the superficial femoral veins was not performed. The absence of a greater saphenous vein was not considered a contraindication for superficial femoropopliteal vein harvesting. Broad spectrum antibiotics were administered to all patients intravenously from the moment of the diagnosis of graft infection.

ACCEPTED MANUSCRIPT Operative technique and postoperative phase In elective setting, the operation commences by harvesting the superficial femoral vein in one or, if needed, both legs. An incision is made on the medial side of the upper leg. The common femoral vein and deep femoral vein are preserved to prevent venous outflow obstruction. Also the greater

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saphenous vein, if present, is preserved. The proximal and distal transections of the superficial

femoral vein are made at the level of the junction with the deep femoral vein and at the knee joint. The popliteal collateral veins to the deep system are kept intact. After harvesting the vein, the leg

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incision is closed prior to laparotomy to avoid contamination. After a median laparotomy a thorough retroperitoneal debridement is performed removing any macroscopically infected tissue , fluid

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collections and vascular graft material. Samples from the aortic wall, fluid collections and the prosthetic graft are isolated for cultures. The vein or veins are then reversed and sutured with a monofilament thread in a tube or bifurcated configuration, dependent on the anatomy (Figure 3 and 4). The proximal aortic anastomosis is sutured in an end-to-end fashion. The autogenous grafts are

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covered with greater omentum if possible. In emergency setting, a median laparotomy is performed prior to vein harvesting. Postoperatively patients are heparinized and given oral anticoagulants for six months after which acetylsalicylic acid 80mg a day is prescribed. Elastic stockings are not distributed

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routinely. Patients are treated with broad spectrum antibiotics for a minimum of 6 weeks postoperatively. Antibiotic regime is tailored if necessary dependent on the outcome of blood-,

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needle aspiration- or graft material cultures.

ACCEPTED MANUSCRIPT Results Clinical signs and radiologic outcomes Two patients presented with fever on hospital admission, four with abdominal or back pain, two with

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a groin wound infection after previous surgery, one with hematemesis and five patients presented with general malaise. Clinical and radiological data are summarized in table I. C-reactive protein levels were elevated in nine of 14 patients with a value of 70 mg/L (<5-199). The leukocyte count was

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normal in all patients. Four patients had positive blood cultures with micro-organisms. We isolated a wide variety of micro-organisms from intraoperative cultures of retroperitoneal fluid collections,

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prosthesis or the aneurysm wall. The antibiotic treatment regimen was equally wide to the variety of isolated bacteria. The choice for antibiotic treatment was dependent on the outcome of cultures and discussed with our department of infectious diseases. Patients were treated with piperacilline/tazobactam, doxycyclin, hydroxychlorokinin, vancomycin, tobramycin, colistin, meropenem, cotrimoxazole, plaquenil and ceftriaxone when appropriate. CT scanning was

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performed preoperatively in seven patients. A preoperative PET-CT scan was performed in the remainder of the patients. Signs suggestive for prosthetic graft infection were found in all scans. These signs included increased fluorodeoxyglucose (FDG) uptake of the aortic prosthesis or aneurysm

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wall in seven cases, the presence of fluid or gas collections in the aneurysm and retroperitoneal

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cavity in 11 patients, intravenous contrast in the duodenum in one patient, anastomotic leakage of a dacron prosthesis in one patient and luxation of an endovascular prosthesis in another. The interval between the primary vascular reconstruction of the aorta and diagnosis of graft infection was 16 months (1 month-13 years). Operative data A venous reconstruction of the aorta with two superficial femoro-popliteal veins was performed in 10 patients. One superficial femoro-popliteal vein was sufficient for reconstruction in four patients. Standardly, we harvested the vein from the right leg.. We implanted a bifurcated venous graft in

ACCEPTED MANUSCRIPT eight patients and a tube configuration in six. We required 2 veins for a tube reconstruction in 2 patients. The iliac bifurcation was too wide to suture the distal anastomosis with 1 vein. -Infected prosthetic grafts: Previous aortic surgery was performed in 11 patients. Open aneurysm repair with insertion of a Dacron prosthesis was the primary operation in seven patients. One of

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these patients was treated for a ruptured aortic aneurysm. Four patients were primarily treated with an endovascular prosthesis. Nine of the 11 patients described above were operated in a semi-

elective setting for an infected prosthetic graft; two patients were operated acutely. These two

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patients displayed signs of hypovolemic shock during admission at the emergency room caused by bleeding from an aorto-duodenal fistula in one and proximal anastomotic leakage of an aorto-bi-

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femoral bypass in another. A median laparotomy was performed prior to vein harvesting in these patients. Two patients had a concomitant spondylodiscitis of lumbar vertebra. In one of these cases the corpus of the third lumbar vertebra suffered severe damage almost causing paraplegia. Prior to venous reconstruction this patient underwent spondylodesis. All prosthetic grafts were completely

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explanted.

-Mycotic aneurysms: Three patients were primarily treated with a femoro-popliteal vein reconstruction of the aorta. Two of these patients were operated in a semi-elective setting. One

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patient was operated acutely for bleeding from a fistula between the aorta and sigmoid colon caused

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by a mycotic aneurysm. A median laparotomy was performed prior to vein harvesting in this patient. The second patient had a chronic coxiella burnetii (Q-Fever) infection and a concomitant spondylodiscitis. The third patient was diagnosed with a saccular aneurysm and an abscess in the psoas major muscle caused by a salmonella infection. Primary outcome measures Four Patients (28%) died within 30 days postoperatively. One patient died of a cerebrovascular accident five days postoperatively. Another patient died after multiple re-operations. This patient was diagnosed with a mycotic aneurysm and operated acutely due to hypovolemic shock caused by

ACCEPTED MANUSCRIPT bleeding from a fistula between the sigmoid colon and the aorta. The postoperative phase was complicated by leakage of the proximal anastomosis, an iatrogenic duodenal perforation and a splenic laceration. The patient required three additional laparotomies in which a resection of the horizontal part of the duodenum, a splenectomy and re-suturing of the proximal venous graft

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anastomosis was performed. The third patient died of a hypovolemic shock. This patient was suspected of retroperitoneal bleeding but this was never verified on CT scan. The fourth patient was re-operated two days after venous reconstruction for an abdominal sepsis. Peroperatively, general

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superficial patchy necrosis of the smaller intestine was found, possibly due to a prolonged

hypoperfusion status at the intensive care. Two weeks thereafter an intra-abdominal fluid collection

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was drained which contained faeces. The patient refused to undergo another laparotomy and died in a palliative setting. One patient died at home 2 years after surgery of unknown cause. Secondary outcome measures

The intra-operative blood loss was 1500 mL (500-8000). Operating time was 364 minutes (264-540).

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The length of stay at the intensive care unit was 3,5 days (1-47). One patient required temporary haemodialysis. Two patients required a re-operation for a failing venous aortic graft. In one patient we implanted a venous graft as a femoro-femoral crossover bypass after occlusion of one iliac limb of

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the venous aortic bifurcated graft. The venous graft completely occluded in another patient which

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necessitated us to implant an extra-anatomical axillo-bi-femoral bypass. 12 grafts remained fully patent during our follow-up. Ten patients survived to hospital discharge after a stay of 20 days (1047). We detected two postoperative wound infections in two patients in the groin region. Limb amputation was not performed in any patients. There were no late amputations. Two patients had mild oedema of the donor limbs postoperatively but none required compression stockings after hospital discharge. Eventually patients reported minimal disability from the removal of the deep veins. Median follow-up was one year (60 days – 2,5 years). Patients were followed by combinations of diagnostics. These included physical examination, leukocyte and c-reactive protein count, duplex

ACCEPTED MANUSCRIPT and CT and or PET-CT scanning. No signs of recurrent aortic infection were detected in the surviving

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patients.

ACCEPTED MANUSCRIPT Discussion

The available literature about aortic infections and subsequent reconstruction consists of studies with a relative small number of patients. No large randomised controlled trials concerning the

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treatment of aortic infection exist due to the rarity of the disaese. We included 14 patients and analysed data retrospectively, thus we are also limited by a small sample size.

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Vascular reconstruction

The available literature recommends an aggressive, combined surgical and antimicrobial treatment

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with removal of all contaminated prosthetic material and subsequent vascular reconstruction (8). An extra-anatomical bypass used to be the surgeons first choice. Laser et al. argue that when blood- or abscess cultures are positive an extra-anatomical reconstruction is preferable (3). The latter implies oversuturing the infrarenal aorta after resection of the infected area; thus creating an aortic stump. Stump rupture is associated with high mortality rates. Bacourt and co-workers described 8 stump

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ruptures in 98 patients and treated 2 ruptures successfully. Moreover, amputation rates of 10-15% following graft failure have been described in various studies. Seeger described a peri-operative mortality rate of 19% and Yeager described a 5-year survival of 47% of patients treated with an extra-

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anatomical bypass for aortic infection (9,10,11,12).

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A rifampicin soaked dacron prosthesis is a feasible in-situ alternative for aortic reconstruction. Rifampicin is bactericidal to gram positive bacteria. It easily binds to the gelatine and collagen that are used to impregnate polyester grafts. Various studies described a 8-18% mortality rate and a higher percentage of re-infection compared to extra-anatomic reconstruction. Young et al described a 22% re-infection rate (13,14). An alternative treatment is implantation of a cryopreserved allograft. However, allografts may degenerate due to immune responses of the recipient. Kitamura performed aortic reconstructions with cryopreserved allografts and reported an early mortality rate of 38% (11). Touma and co-

ACCEPTED MANUSCRIPT workers evaluated overall survival and complications of cryopreserved allografts in aortic graft infections and infected aortic aneurysms. Their 30-day mortality rate was 28% with an overall mortality of 39% at 12.1 months (15). Antibiotic suppletion combined with percutaneous drainage of fluid collections adjacent to the aorta

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without surgical debridement is an alternative treatment for patients unfit for open surgery. Various studies describe high mortality rates of 46 to 70%. Cernohorsky presented a 16% mortality in one

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year in selected cases treated conservatively (8).

In situ autogenous reconstruction is described as a feasible treatment option for aortic infection,

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providing good long-term survival and limb salvage (16). A recent Dutch study identified in situ venous reconstruction as the first treatment choice in 63% of vascular surgeons and 52% of vascular surgeons in training (17). The treatment ensures an in situ anatomical reconstruction, absence of an aortic stump and the absence of a prosthetic graft. The technique is less commonly used because of the technical complexity and duration of the operation. Some argue that prolonged operating time

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might increase the risk of mortality. However, deep femoro-popliteal veins are particularly suitable for their availability, length, diameter and high resistance to infection. Our results indicate that harvesting the deep veins is well tolerated due to the extensive collateral venous network in the leg.

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The saphenous vein is usually too small for aortic reconstruction unless sutured in spiral

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configuration. Clagett reported a failure rate of 64% after saphenous vein reconstruction compared to 0% for deep vein reconstruction(18). Infection

The diagnosis of aortic infection is based on a combination of clinical findings and tests. Patients present various clinical symptoms such as gastro-intestinal haemorrhage related to an aortic-enteric fistula, sepsis, septic emboli, graft thrombosis, fever, pelvic, abdominal or back pain, tachycardia and hypotension. However, the symptoms and complaints may be vague and non-specific. Laboratory findings may display leucocytosis, a rise in C-reactive protein and positive blood cultures (3). In our

ACCEPTED MANUSCRIPT series, the leukocyte count was normal in all patients. The diagnosis is supported by gas or fluid collections in the aneurysm sac, pseudo-aneurysm formation or adjacent fluid collections on radiologic imaging. Pathogens involved are coagulase negative staphylococcus and staphylococcus aureus in 78% of patients (4,5). Additional studies report staphylococcus aureus as the dominant

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pathogen of aortic infections. Other organisms include salmonella, acinetobacter, pseudomonas aeruginosa, escherichia coli, enterococcus faecalis, streptococcus, bacteroides and candida (8,11,19). Our series also demonstrates a wide variety of pathogens in cultures. We were able to eradicate the

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infection in all surviving patients and detected no re-infections in our patient group. These findings are concurrent with other studies. Daenens and Clagett report a 0% re-infection percentage of

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patients treated with a venous reconstruction of the aorta (6,18). Coxiella burnetii

Four patients were infected with coxiella burnetii in our series. Two of these patient had a primary aortic infection, the other two patients an infected endovascular prosthesis. Q-fever is a zoonosis,

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caused by the Gram-negative coccobacillus coxiella burnetii. The most common source of human infections is a large animal reservoir, with goats, sheep and cattle. Q-fever infections are frequently associated with cardiovascular complications mainly endocarditis, aortic aneurysms and vascular-

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graft infections. The incidence of Q-fever infected vascular prosthesis is 8% in all diagnosed vascular

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prosthetic infections. Currently, no guidelines exist for the antibiotic treatment of vascular Q-fever. Patients are treated with a great variety of antibiotics for example doxycyclin and hydroxychlorokinin (20).

Mortality rates

The first report that describes autologous aortic reconstruction dates from the year 1979. Nevelsteen reported an early mortality rate of 7%. A more recent series reported a 30-day mortality rate of 4.3% in femoro-popliteal vein reconstruction (21). From the same group Daenens analysed the largest population of 49 patients who received autologous vein reconstruction for primary aortic graft

ACCEPTED MANUSCRIPT infections. They report a mortality rate of 8% postoperatively and of 40% at 5 years follow-up (6). The late deaths were unrelated to the operation. Bandyk presented a 4% peri-operative mortality and pointed out that autogenous reconstruction is superior to in situ prosthetic reconstruction in reducing re-infections (19). Clagett supported these data with a death rate of 10% postoperatively

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(18). In our series four patients died within 30 days which accounts for an early mortality of 28%. This may be explained by an unfavourable patient selection, as our series includes several acute cases of aortic rupture and severe sepsis. Concurrent with our findings, Cernohorsky reported an overall

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mortality of 25% in 12 cases in which four endografts were removed (8).

ACCEPTED MANUSCRIPT Conclusion

We conclude that autogenous superficial femoro-popliteal vein reconstruction of the aorta in the treatment of infection seems advantageous over other therapeutic approaches. Mortality rates

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compare favourably to antibiotic treatment alone and opposed to extra-anatomic reconstructions stump rupture and limb loss does not occur. The venous reconstruction offers excellent infection control. Autologous reconstruction of the aorta deserves a prominent place in the treatment of the

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primary infected aorta or an infected aortic prosthetic graft.

ACCEPTED MANUSCRIPT References 1. Huang YK, Chen CL, Lu MS. Clinical, Microbiologic, and Outcome Analysis of Mycotic Aortic Aneurysm: The Role of Endovascular Repair. Surg Infect (Larchmt). 2014 Jun;15(3):290-8.

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2. Steverlynck L, Van de Walle S. Mycotic thoracic aortic aneurysm: review of the diagnostic and therapeutic options. Acta Clin Belg. 2013 May-Jun;68(3):193-8. 3. Laser A, Baker N, Rectenwald J. Graft infection after endovascular abdominal aortic aneurysm repair. J Vasc Surg 2011; 54:58-63.

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4. Hobbs SD, Kumar S, Gilling-Smith GL. Epidemiology and diagnosis of endograft infection. J Cardiovasc Sur. 2010; 51:5-14.

5. Wilson SE. New alternatives in management of the infected vascular prosthesis. Surgical Infections. 2001; 2(2): 171-177.

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6. Daenens K, Fourneau I, Nevelsteen A. Ten-year experience in autogenous reconstruction with the femoral vein in the treatment of aortofemoral prosthetic infection. Eur J Vasc Endovasc Surg 2003; 25:240-245. 7. Saleem BR, Meerwaldt R, Tielliu IFJ. Conservative treatment of vascular prosthetic graft infection is associated with high mortality. Am J Surg 2010; 200:47-52.

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8. Cernohorsky P, Reijnen MPJ, Tielliu IFJ. The relevance of aortic endograft prosthetic infection. J Vasc Surg 2011; 54(2): 327-333. 9. Yeager RA, Porter JM. Arterial and prosthetic graft infection. Ann Vasc Surg 1992; 6:485-491.

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10. Bacourt F, Koskas F and the French university association for research in surgery. Axillo-bifemoral bypass and aortic exclusion for vascular septic lesions: a multicenter retrospective study of 98 cases. Ann Vasc Surg 1992; 6:119-126.

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11. Kitamura T, Morota T, Motomura N. Management of infected grafts and aneurysms of the aorta. Ann Vasc Surg 2005; 19:1-8. 12. Seeger JM, Pretus HA, Welborn MB. Long-term outcome after treatment of aortic graft infection with staged extra-anatomic bypass grafting and aortic graft removal. J Vasc Surg 2000; 32(3): 451461. 13. Hayes PD, Nasim A, London NJ. In situ replacement of infected aortic grafts with rifampicinbonded prostheses: the Leicester experience. J Vasc Surg. 1999; 30(1): 92-98. 14. Young RM, Cherry KJ Jr, Davis PM. The results of in situ prosthetic replacement for infected aortic grafts. Am J Surg. 1999; 178(2): 136-140. 15. Touma J, Cochennec F, Parisot J. In situ reconstruction in native and prosthetic aortic infections using cryopreserved arterial allografts. Eur J Vasc Endovasc Surg. 2014 Sep;48(3):292-9

ACCEPTED MANUSCRIPT 16. Ehsan O, Gibbons CP. A 10-year experience of using femoro-popliteal vein for re-vascularisation in graft and arterial infections. Eur J Vasc Endovasc Surg. 2009 Aug;38(2):172-9. 17. Berger P, De Borst GJ, Moll FL. Current opinions about diagnosis and treatment strategy for aortic graft infections in The Netherlands. J Cardiovasc Surg. 2013.

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18. Clagett GP, Bowers BL, Lopez-Viego MA. Creation of a neo-aortoiliac system from lower extremity deep and superficial veins. Ann Surg 1993;218:239. 19. Bandyk D, Novotney ML, Johnson B. Use of rifampicin-soaked gelatin-sealed polyester grafts for in situ treatment of primary aortic and vascular prosthetic infections. J Surg Research. 2001; 95:4449.

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20. Wegdam MC, Vainas T, van Sambeek MR. Vascular complications of Q-fever infections. Eur J Vasc Endovasc Surg. 2011 Sep;42(3):384-92

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21. Nevelsteen A, Lacroix H, Sau R. Autogenous reconstruction with the lower extremity deep veins: an alternative treatment of prosthetic infection after reconstructive surgery for aortoiliac disease. J Vasc Surg 1995; 22:129-34.

ACCEPTED MANUSCRIPT Title of table (enclosed as separate file)

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Table 1 - Patient data

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Titles of figures (enclosed as separate file)

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Figure 1 - Infected Dacron prosthesis with a large defect in the duodenum. Green erosion of the Dacron graft caused by duodenal fluids.

Figure 2 - PET-CT Scan of an infected aorta with increased FDG-uptake and concomitant spondylodiscitis of lumbar vertebra three.

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Figure 4 - Implanted bifurcated venous graft.

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Figure 3 - Two superficial femoral veins sutured in a bifurcated configuration.

Gender

Age

Blood cultures

Serology

Type infected graft

PET/CT-scan

Graft cultures

30-day death

1

Male

68

Negative

Negative

Peri-aortitis and aortic graft infection

Negative

No

2

Male

75

Negative

Negative

Open Dacron aorto-bi-femoral with groin abcess Open Dacron

Gas and fluid in the aneurysm sac

Enterococcus faecium

No

3

Female

69

Negative

Negative

Open Dacron

Negative

No

4

Male

66

Negative

Lues

Negative

No

5

Male

78

Negative

Negative

EVAR, with metastatic abcesses in the right hip Open dacron

Increased prosthetic FDG-uptake Proximal type I endoleak

Gas in aneurysm sac and contract in duodenum

Streptococcus milleri, acternomyces

Yes, cerebro vascular accident

6

Female

75

Negative

Coxiella Burnetii

None

Infection aneurysm sac wth spondylodiscitis

-

No

7

Male

76

Streptococcus epidermidis

Negative

Open dacron

Aorto-duodenal fistula

Streptococcus epidermidis, hemolytic streptococcus and anaerobe flora

Yes, hypovolemic shock

8

Male

73

Negative

Coxiella Burnetii

None

Mycotic aneurysm with sigmoidal fistula

-

Yes, abdominal sepsis

9

Male

62

Bacteriodes fragillis

Negative

EVAR

False aneurysm distal to stentgraft with spondylodiscitis

bacteriodes fragillis

No

10

Male

64

Propioni bacterium acnes

11

Male

71

12

Male

63

13

Female

14

Female

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Open Dacron

Infected prothesis with aorto-duodenal fistula

Candida glabrata, fusobacterium nucleatum, lactobacillus

No

Negative

Coxiella Burnetii

EVAR

Peri-aortitis and air in aneurysm sac

E. Coli, Coxiella Burnetii

No

Negative

Coxiella Burnetii

EVAR

Peri-aortitis, fluid and air in aneurysm sac

Candida, Coxiella Burnetii

No

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Negative

57

Negative

Negative

Open Dacron

Infected prothesis with aorto-duodenal fistula

Candida tropicalis and albicans

Yes, abdominal sepsis

63

Salmonella

Negative

None

Mycotic aneurysm with retroperitoneal abscess

-

No

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