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Use of superficial femoral vein in the treatment of infected aortoiliofemoral prosthetic grafts
Cardiovascular Surgery, Vol. 10, No. 4, pp. 304–310, 2002 2002 The International Society for Cardiovascular Surgery Published by Elsevier Science Ltd. All rights reserved 0967-2109/02 $22.00
PII: S0967-2109(02)00024-8
www.elsevier.com/locate/cardiosur
Use of superficial femoral vein in the treatment of infected aortoiliofemoral prosthetic grafts M. A. Cardozo, A. D. Frankini and T. P. Bonamigo Discipline of Angiology and Vascular Surgery, Fundac¸a˜o Faculdade Federal de Cieˆncias Me´dicas, Porto Alegre, RS, Brazil Purpose: To assess the use of the superficial femoral vein for the reconstruction of the aortoiliofemoral sector in the treatment of prosthetic infections. Methods: From December 1995 to November 1999, 12 patients with infection involving a synthetic vascular prosthesis were submitted to thirteen surgical procedures involving partial or total resection of a synthetic vascular prosthesis and restoration of arterial flow with an in situ femoral vein. Results: The overall operative mortality rate was 15.3% (2 out of 3 patients who underwent total graft replacement and 0 out of 9 patients who underwent unilateral graft replacement). Major amputations related to the surgical procedures were performed in two cases (an 87.5% rate of limb salvage). The series was followed up on average for 22 months (range: 6–65 months). No patient presented clinically significant edema or signs of chronic venous insufficiency in the lower limbs used as donors of autogenous venous grafts. All surviving patients presented complete resolution of the infectious signs and symptoms and none of them presented late thrombosis of the venous graft. Conclusion: The use of the superficial femoral vein is a good surgical alternative for the treatment of prosthetic infections with minimal venous morbidity of the lower limbs used as venous graft donors. The autogenous venous grafts present good long-term patency and excellent adaptation to the aortoiliofemoral position. 2002 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved Keywords: aorta abdominal, aortic diseases, infection, femoral vein, reoperation, prosthesis failure
Introduction The management of synthetic vascular prosthetic infections has been a constant challenge to vascular surgeons. Several surgical alternatives have been proposed, with mortality rates ranging from 10.0 to 36.0% and lower limb amputation rates ranging from 10.0 to 45.0%, as reported in literature reviews [1, 2]. The treatment most frequently used consists of removal of the infected prosthetic graft and restoration of arterial blood flow to the lower limbs by
Correspondence to: M. A. Cardozo, Rua Marqueˆs do Pombal, 1199/401, 90540-001 Porto Alegre, RS, Brazil. Tel.: +55-51-3372306; fax: +55-51-337-2306; e-mail: [email protected]
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the extraanatomical route [2, 3]. Successful series have been reported over the last few years, showing the efficiency of deep veins of the lower limbs for autogenous reconstruction in the treatment of prosthetic infection [1, 4–12]. In the present study we report our experience with the use of a superficial femoral vein for reconstruction of the aortoiliofemoral sector in the treatment of infected prosthetic grafts.
Patients From December 1995 to November 1999, twelve patients (11 men and 1 woman) with infected synthetic vascular prosthetic grafts in the aortoiliofemoral sector were submitted to thirteen surgical proCARDIOVASCULAR SURGERY
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Treatment of infected aortoiliofemoral prosthetic grafts: M. A. Cardozo et al.
cedures for partial or total graft removal and replacement with a superficial femoral vein. The patient age ranged from 40 to 80 years (mean, 61.2 years). Previous arterial restoration surgery was performed due to aortoiliac obstructive diseases in 5 patients, due to an abdominal aorta aneurysm in five, and due to vascular trauma in two (Table 1). One these patients was submitted to correction of a femoral anastomotic pseudoaneurysm six years after implantation of the aortobifemoral prosthesis (case 9). A precoagulated Dacron prosthesis was used in 11 previous operations and an expanded polytetrafluoroethylene prosthesis was used in one. The time elapsed between previous arterial restoration surgery and patient hospitalization with symptoms of prosthetic infection ranged from 16 days to 74 months (mean, 23 months). All patients were admitted with a primary infection of the vascular prosthesis. Signs of sepsis (fever and leukocytosis) were observed in ten cases. Most of the presenting symptoms were located at the level of the groin, but two patients presented with a retroperitoneal abscess. The infections were due to a variety of organisms, with staphylococci being the most frequent (Table 1).
Methods Surgical treatment with partial or total prosthesis removal, restoration of arterial flow with a deep vein from the lower limbs and antibiotic treatment were indicated for patients with a clinical and/or laboratory and/or tomographic diagnosis of infection involving the synthetic vascular graft in the aortoili-
ofemoral sector. The decision about total or partial graft removal was based on clinical signs and symptoms, on computer tomography of the abdomen and on the type of bacteria responsible for the infection. The patients submitted to total graft replacement were the ones who were prostrated, had fever, leukocytosis, and showed a worsening of the infection. Their computer tomography showed involvement of the prosthesis’ body and limbs. They also had gramnegative infections which could also be associated with non-aerobic bacteria. Patency of the lower extremity deep veins was confirmed preoperatively by duplex scan in 11 patients. Two patients were not submitted to this examination because they needed urgent operation. The basic techniques for this operation were described by Clagett et al. [1] in 1993. Intravenous antibiotic therapy is started before the operation and continued until discharge to patient with total graft resection or continued for 6 weeks to patient with partial graft resection. Complete removal of the aortobifemoral prosthetic graft and restoration of arterial flow in situ using two superficial femoral veins with end-to-end anastomosis in the abdominal aorta was performed in three cases (Figure 1). Exchange of a branch of the aortobifemoral prosthetic graft with a superficial femoral vein in situ was performed in six cases. This exchange was performed via extra peritoneal access and dissection of the groin area. Extreme care was taken to avoid exposition and contamination of the remaining prosthesis. In one of these cases simultaneous femorotibial revascularization with a homolateral saphenous vein was required due to associated decompensated distal ischemia. In another patient,
Table 1
Demographic data and presenting symptoms in 12 patients (13 cases)
No
Sex/age
Primary operation
Presenting symptoms
Organisms
1 2a 3 4 5 6
M/70 M/40 M/53 M/58 M/56 F/80
AAA:AF2 PG T: IF PG AIOD: AF2 PG AIOD: AF2 PG AIOD: AF2 PG AAA:AI2 PG
S. epidermidis No growth Enterobacter aerogenes S. aureus+E. coli S. aureus Proteus mirabilis+Bacteroides fragilis
7a
M/49
AIOD: AF2 PG
8 9 10b 11 12b 13
M/67 M/63 M/77 M/68 M/78 M/54
T: IF PG+FP PG AAA: AF2 PG AAA: AF2 PG AIOD: AF2 PG AAA: AF2 PG AAA: AF2 PG
Draining groin sinus fever+leukocytosis Femoral anastomotic rupture fever+leukocytosis Draining groin sinus (bilateral) fever+leukocytosis Groin abscess fever+leukocytosis Draining groin sinus fever+leukocytosis Anastomotic aortic aneurysm, Retroperitoneal abscess fever+leukocytoses Draining groin sinus, femoral anastomotic rupture fever+leukocitosis Draining groin sinus fever+leukocytosis Draining groin sinus Draining groin sinus Weigth loss Retroperitoneal abscess fever+leukocytosis Draining groin fistula Anastomotic femoral aneurysm, perigraft mass fever+leukocytosis
S. aureus S. aureus S. epidermidis No growth S. aureus No growth (gram-positive cocci) No growth
AAA, abdominal aortic aneurysm; AF2, aortobifemoral; AI2, aortobiiliac; AIOD, aortoiliac occlusive disease; F, female; Ftib, femorotibial; IF, iliofemoral; M, male; PG, prosthetic graft; S, Staphylococcus; T, trauma; VG, venous graft. a Emergency cases. b The same patient.
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Treatment of infected aortoiliofemoral prosthetic grafts: M. A. Cardozo et al.
two superficial femoral veins were used and the distal anastomosis was performed in the popliteal artery above the knee (case 7). Exchange of the two branches of the aortobifemoral prosthetic graft with a superficial femoral vein, with an 8-month interval between operations, was performed in one patient previously submitted to various femoral catheterizations through the prosthesis for the diagnosis and treatment of obstructive coronary disease (cases 10 and 12). The body of the aortofemural bypass graft was left in place after the second procedure. This patient never presented clinical symptoms of sepsis and the computer tomographies did not show involvement of the prosthesis’ body, neither before nor after surgery. The infection of the other graft limb took place around 25 days after coronary angioplasty by femoral catheterism via prosthesis. The surgical technique which was used for the exchange of both branches was the same which was previously described for the partial graft replacement cases. Complete removal of the iliofemoral prosthetic graft and revascularization with a superficial femoral vein in situ was performed in two cases and one of them was submitted to removal of an associated femoropopliteal prosthetic graft without requiring distal revascularization (Table 2). Angiography was performed in four patients before discharge for the control and documentation of selected cases. After discharge, all patients were observed at 6-month intervals. Follow-up included clinical vascular examination and duplex scan examination of the reconstruction and of the donor graft limb.
Results All surviving patients presented complete resolution of the infectious picture and none of them presented late thrombosis of the venous graft. The angiographic examination performed on four patients was considered to be satisfactory in all cases (Figure 2). No clinically significant lower limb edema was
observed in any patient after dissection of the superficial femoral vein. Two thigh amputations were performed (limb salvage rate of 87.5%). One patient who had femoropopliteal and distal occlusion of the left leg under control before surgery presented serious ischemic symptoms right after the surgery. These symptoms did not show sign of improvement after clinical treatment; they led to the amputation of the leg on the second day due to irreversible ischemia. No attempt at distal revascularization was made due to the persistence of the septic picture and the poor clinical condition of the patient. At the time of amputation the venous graft was patent and ischemia was attributed to thrombosis of the distal microcirculation during arterial clamping (case 6). Another patient presented pseudoaneurysm of the anastomosis between the superficial femoral veins. The pseudoaneurysm was resected and the venous graft presented thrombosis with irreversible ischemia of the lower limb on the 47th postoperative day. This patient had severe chronic arterial obstructive disease. The thrombosis of the venous graft was due to a poor runoff (Table 2). The overall surgical mortality was 15.3%. One patient submitted to complete removal of the aortobifemoral prosthetic graft and reconstruction with two femoral veins died two days after operation due to sepsis and multiple organ failure. Another patient submitted to complete removal of the aortobiiliac prosthetic graft and reconstruction with superficial femoral veins died of sepsis and hemorrhage due to suture dehiscence in the anastomosis of the proximal aorta on the eighth day after operation (Table 2). Patient follow-up ranged from 6 to 65 months (mean, 22 months). The data of the present study have been computed up to May 2000. There was no mortality related to the surgical procedure during follow-up. One patient was admitted during the 13th follow-up month with a trophic lesion of the heel that did not respond satisfactorily to treatment, requiring thigh amputation in spite of the venous grafts being patent at the time of amputation (Table 2). Duplex scan of the venous graft was performed in 10 cases at 6 month intervals after surgery and did not show signs of aneurysmatic dilatation or focal stenosis between the 6th and 65th month of followup (Figure 3). No edema or signs of chronic venous insufficiency were observed in the lower limbs used as self-graft donors, and duplex scan examination of these limbs did not reveal deep venous thrombosis or important reflux of venous circulation during follow-up (Figure 4a and b).
Figure 1 Intraoperative photograph of the aortobifemoral restoration with superficial femoral veins (case 4).
306
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Treatment of infected aortoiliofemoral prosthetic grafts: M. A. Cardozo et al. Table 2 Methods of repair and clinical outcome in 12 patients (13 cases) No
Primary operation
Repair
Clinical outcome
1 2a 3 4 5
AF2 PG IF PG AF2 PG AF2 PG AF2 PG
AF1 DVG (in situ) IF DVG (in situ) AF2 DVG (in situ) AF2 DVG (in situ) AF1 DVG (in situ)+Ftib VHG
6 7a 8 9
AI2 PG AF2 PG IF PG+FP PG AF2 PG
AF2 DVG (in situ) AF1 DVG (in situ) IF DVG (in situ) AF1 DVG (in situ)
10b 11 12b 13
AF2 AF2 AF2 AF2
AF1 AF1 AF1 AF1
Alive and well (65 months) Alive and well (40 months) 2 days death (sepsis) Alive and well (36 months) ABA 13 months after operation (lost after 21 months) 8 days death (sepsis+hemorrhage) 47 days ABA (thrombosis) Alive and well (25 months) Died of myocardial infarction after 10 months Alive and well (13 months) Alive and well (8 months) Alive and well (6 months) Alive and well (6 months)
PG PG PG PG
DVG DVG DVG DVG
(in (in (in (in
situ) situ) situ) situ)
ABA, above-knee amputation; AF1, aortounifemoral; AF2, aortobifemoral; AI2, aortobiiliac; DVG, deep vein graft; FP, femoropopliteal; Ftib, femorotibial; IF, iliofemoral; PG, prosthetic graft; VHG, venous homograft. a Emergency cases. b The same patient.
Figure 3 Duplex scan of the aortobifemoral restoration with superficial femoral veins, performed during the 36th postoperative month, demonstrating patency of the anastomoses.
Discussion
Figure 2 Postoperative angiography of an aortobifemoral restoration with superficial femoral veins (case 4).
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The conduct most commonly adopted for cases of synthetic vascular prosthetic infection in the aortoiliofemoral sector is extranatomical revascularization through areas not involved by infection and removal of the aortic prosthetic graft. Mortality varies around 19.4% and the amputation rate is about 10.5%, as reported in a review by Clagett et al. [1]. The most feared early complications of this surgical strategy are infection of the extra-anatomical bridge (16.0% of cases) and dehiscence of the aortic stump (8.5% of cases) [1]. On a medium- and long-term basis, thrombosis of the extra-anatomical graft may be 307
Treatment of infected aortoiliofemoral prosthetic grafts: M. A. Cardozo et al.
Figure 4 Photograph taken during the 36th month of follow-up showing the absence of edema of the lower limbs after dissection of the superficial femoral veins used for aortobifemoral reconstruction (case 4) (a) and venous duplex scan of a lower limb performed during the 36th postoperative month showing the absence of deep thrombosis and the patency of the tibial and popliteal veins below the knee (case 4) (b).
catastrophic since it frequently leads to the need for major amputations. In patients with severe obstructive vascular disease, the axillopopliteal and axillofemoral bridges have presented a 43.0% rate of primary patency over a period of three years, with one 308
third of all survivors eventually requiring major amputation [13]. Dissatisfaction with these results has led several surgeons to consider surgical alternatives such as in situ reconstruction with autologous deeps veins from the lower limbs [1, 4–12, 14]. The use of autogenous material in combination with antibiotic treatment is an effective strategy for the control and eradication of infection. In 1979, Ehrenfeld et al. [15] demonstrated the resistance of endarterectomized aortoiliofemoral arterial segments and of saphenous veins as arterial substitutes after removal of infected prostheses. However, the medium- and long-term results obtained with these arterial substitutes in the aortoiliofemoral position present high rates of focal stenosis and thrombosis due to progressive neointimal hyperplasia [1, 16, 17]. In 1991, Fokin et al. [4] reported on a series of 12 patients in whom deep veins from the lower limbs were used for the treatment of infected vascular prostheses in the inguinal region. In 1993, Clagett et al. [1] demonstrated that the superficial femoral veins are less susceptible to late degeneration and to focal stenosis and, by being of wider diameter, are better adapted to the aortoiliofemoral position than saphenous veins. They demonstrated 100% patency for superficial femoral veins and 36% patency for saphenous veins after two years of follow-up. Nevelsteen et al. [6], after treating 15 patients with vascular prosthetic infection using deep veins from the lower limbs, also reported promising results. Clagett et al. [1] pointed out that for a successful reconstruction of arterial flow it is necessary to have an autogenous venous graft of wide caliber, with no signs of previous disease. During preoperative evaluation, they recommend duplex scan study of veins from the lower limbs. Fortunately, the patients in our series who were not submitted to duplex scan because of the urgency of the procedure had good quality superficial femoral veins. We observed no clinically significant edema in none of the lower limbs used as donors of the autogenous venous graft. The duplex scan of these limbs performed during the late postoperative period did not reveal deep venous thrombosis or important reflux of the venous circulation. No patient developed clinical signs of chronic venous stasis. This observation has also been reported by authors who utilized deep veins of the lower limbs as peripheral arterial substitutes and especially femoropopliteal shunts [18–22]. Recently, Wells et al. [23] studied 86 lower limbs of 61 patients treated with the superficial femoral vein removed for use in aortoiliofemoral shunts after removal of the infected prosthetic graft, in a femoropopliteal shunt or in major venous reconstruction. Patient follow-up ranged from three to 37 months. No patient presented signs of chronic venous insufficiency or limping of venous origin and the results were not CARDIOVASCULAR SURGERY
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influenced by the presence or absence of the ipsilateral magna saphenous vein. Major amputations of the lower limbs related to the surgical procedure were performed in two cases, with a limb salvage index of 87.5%. Fokin et al. [4] reported two major amputations in their patients. In two different series, Clagett et al. [1, 7] reported a 10.0% and a 4.8% amputation rate in patients with prosthetic infection treated with the deep veins from the lower limbs for the reconstruction of the aortofemoral sector. Nevelsteen et al. [6] using the same technique for the treatment of 15 patients, performed a major amputation due to distal obstructive arterial disease and the index of lower limb salvage was 96.0%. Two patients with massive prosthetic infections caused by Gram-negative bacteria kept their sepsis and died due to multiple organ failure in one case, and hemorrhage caused by dehiscence of aortovenous anastomosis suture in the other. Hemorrhage in this second patient probably happened because of the virulence of the infecting organism as the aortic stump was adequately debrided at the time of graft replacement. Gram-negative bacteria, Pseudomonas sp in particular, have the ability to produce proteolytic enzymes (proteases) and the infections are frequently associated with sepsis, tissue necrosis, dehiscence of the anastomosis and rupture of the arteries involved [24–26]. Franke and Voit [8] reported two deaths due to dehiscence of the aortovenous anastomosis in infections caused by Pseudomonas aeruginosa among seven patients. Clagett et al. [1] and Nevelsteen et al. [6] reported a successful outcome in two and three cases, respectively, of vascular prosthetic infection caused by P. aeruginosa treated with a superficial femoral vein in situ. The mortality rate reported by these authors was 7.0% [6] and 9.6% [7]. All patients presented prosthetic infection associated with erosion or an aortoenteric fistula. We did not treat any patient with this condition. In our series, the overall mortality rate was 15.3%. Although the number of patients was not too high and our group was heterogeneous in terms of surgery performed, this general mortality rate has also been published by other authors when they speak about mortality [1, 6, 7]. All survivors presented complete cure of the infection, a fact demonstrating the efficacy of the technique in eradicating the infection and confirming its high cure rate, also observed in other series reported in the literature [1, 4–12]. In addition, this result justifies the partial resection of the prosthetic graft in cases in which the microorganism causing the infection is of low aggressiveness (Staphylococcus epidermidis) or of moderate aggressiveness (Staphylococcus aureus) and in which computed tomography demonstrates the separate involvement of only one branch of the prosthetic graft. CARDIOVASCULAR SURGERY
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The duplex scan of the venous graft did not show signs of aneurysmatic dilatations or focal stenosis between the 6th and 65th month of follow-up in this series. Similar observations were reported by Clagett et al. [7]. The same authors reported an 83.0% rate of primary patency and a 100.0% rate of secondary patency over a five-year follow-up. We did not observe any case of graft thrombosis during followup.
Conclusions The use of the superficial femoral vein is a good surgical alternative for the treatment of synthetic vascular prosthetic graft infection. The course of these infections is significantly affected by the extent of prosthetic graft involvement and by the aggressiveness of the microorganisms involved. The technique has an excellent cure rate. The venous grafts show good long-term patency and an excellent adaptation to the aortoiliofemoral position, with minimal venous morbidity of the lower limbs used as venous graft donors.
References 1. Clagett, G. P., Bowers, B. L., Lopeez-Viego, M. A. et al. Creation of a Neo-aortoiliac system from lower extremity deep and superficial veins. Ann Surg, 1993, 49, 218–239. 2. Bandik, D. F. and Bergamini, T. M. Infection in prosthetic vascular grafts. In., Vascular Surgery, Vol. vol. 1, 4th ed., ed. R. B. Rutherford. Saunders, Philadelphia 1995, pp. 588–604. 3. Sharp, W. J., Hoballah, J. J., Mohan, C. R. et al. The management of the infected aortic prosthesis: a current decade of experience. J Vasc Surg, 1994, 19, 844–850. 4. Fokin, A. A., Zotov, S. P. and Verbovetskii, A. V. Replacement of infected vascular prosthesis by the femoral vein. Khirurgiia Mosk, 1991, 6, 57–59. 5. Nevelsteen, A., Lacroix, H. and Suy, R. The superficial femoral vein as autogenous conduit in the treatment of prosthetic infection. Ann Vasc Surg, 1993, 7, 556–560. 6. Nevelsteen, A., Lacroix, H. and Suy, R. Autogenous reconstruction with the lower extremity deep veins: an alternative in the treatment of prostetic infection after reconstrutive surgery for aortoiliac disease. J Vasc Surg, 1995, 22, 129–134. 7. Clagett, G. P., Valentine, R. J. and Hagino, R. T. Autogenous aortoiliac/femoral reconstruction from superficial femoral-popliteal veins: feasibility and durability. J Vasc Surg, 1997, 25, 255–270. 8. Franke, S. and Voit, R. The superficial femoral vein as arterial substitute in infections of the aortoiliac region. Ann Vasc Surg, 1997, 11, 406–412. 9. Sicard, G. A., Reilly, J. M., Doblas, M. et al. Autologous vein reconstruction in prosthetic graft infections. Eur J Vasc Endovasc Surg, 1997, 14(Suppl A), 93–98. 10. Sladen, J. G., Chen, J. C. and Reid, J. D. S. An agressive local approach to vascular graft infection. Am J Surg, 1998, 176, 222–225. 11. Brown, J. R., Kim, V. B., Lalikos, J. F. et al. Autologous superficial femoral vein for aortic reconstruction in infected fields. Ann Vasc Surg, 1999, 13, 32–36. 12. Gibbons, C. P., Ferguson, C. J., Edwards, K. et al. Use of superficial femoropopliteal vein for suprainguinal arterial reconstruction in the presence of infection. Br J Surg, 2000, 87, 771–776. 13. Quin˜ ones-Baldrich, W. J., Hernandes, J. J. and Moore, W. S.
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14.
15. 16. 17. 18. 19. 20.
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Long-term results following surgical management of aortic graft infection. Arch Surg, 1991, 126, 507–511. Nevelsteen, A. and Suy, R. Autogenous venous reconstruction in the treatment of aortobifemoral prosthetic infection. J Cardiovasc Surg, 1988, 29, 315–317. Ehrenfeld, W. K., Wilbur, B. G., Olcott, C. N. et al. Autogenous tissue recostruction in the management of infected prosthetic grafts. Surgery, 1979, 85, 82–92. Lorentzen, J. E. and Nielsen, O. M. Aortobifemoral bypass with autogenous saphenous vein in treatment of paninfected aortic bifurcation graft. J Vasc Surg, 1986, 3, 666–668. Quin˜ ones-Baldrich, W. J. and Gelabert, H. A. Autogenous tissue reconstruction in the management of aortoiliofemoral graft infection. Ann Vasc Surg, 1990, 4, 223–228. Schanzer, H., Chiang, K., Mabrouk, M. et al. Use of lower extremity deep veins as arterial substitutes: functional status of the donor leg. J Vasc Surg, 1991, 14, 624–627. Schulman, M. L., Schulman, L. G. and Lledo-Perez, A. M. Unusual autogenous vein grafts. Vasc Surg, 1992, 26, 257–264. Masuda, E. M., Kistner, R. L. and Ferris, E. B. III Long term effects of superficial femoral vein ligation: thirteen-year followup. J Vasc Surg, 1992, 16, 741–749.
21. Coburn, M., Ashworth, C., Francis, W. et al. Venous stasis complications of the use of the superficial femoral and popliteal veins for lower extremity bypass. J Vasc Surg, 1993, 17, 1005–1009. 22. Sladen, J. G., Reid, J. D. S., Maxwell, T. M. et al. Superficial femoral vein: a useful autogenous harvest site. J Vasc Surg, 1994, 20, 947–952. 23. Wells, J. K., Hagino, R. T., Bargmann, K. M. et al. Venous morbity after superficial femoral-popliteal vein harvest. J Vasc Surg, 1999, 29, 282–291. 24. Ouriel, K., Geary, K. J., Green, R. M. et al. Fate of the exposed saphenous vein graft. Am J Surg, 1990, 160, 148–150. 25. Geary, K. J., Tomkiewicz, Z. M., Harrison, H. N. et al. Differential effects of a gram-negative and a gram-positive infection on autogenous and prosthetic grafts. J Vasc Surg, 1990, 11, 339– 347. 26. Calligaro, K. D., Veith, F. J., Schwartz, M. L. et al. Selective preservation of infected prosthetic arterial grafts. Ann Surg, 1994, 220, 461–471.
Paper accepted 28 February 2002
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PII: S0967-2109(02)00024-8
www.elsevier.com/locate/cardiosur
Use of superficial femoral vein in the treatment of infected aortoiliofemoral prosthetic grafts M. A. Cardozo, A. D. Frankini and T. P. Bonamigo Discipline of Angiology and Vascular Surgery, Fundac¸a˜o Faculdade Federal de Cieˆncias Me´dicas, Porto Alegre, RS, Brazil Purpose: To assess the use of the superficial femoral vein for the reconstruction of the aortoiliofemoral sector in the treatment of prosthetic infections. Methods: From December 1995 to November 1999, 12 patients with infection involving a synthetic vascular prosthesis were submitted to thirteen surgical procedures involving partial or total resection of a synthetic vascular prosthesis and restoration of arterial flow with an in situ femoral vein. Results: The overall operative mortality rate was 15.3% (2 out of 3 patients who underwent total graft replacement and 0 out of 9 patients who underwent unilateral graft replacement). Major amputations related to the surgical procedures were performed in two cases (an 87.5% rate of limb salvage). The series was followed up on average for 22 months (range: 6–65 months). No patient presented clinically significant edema or signs of chronic venous insufficiency in the lower limbs used as donors of autogenous venous grafts. All surviving patients presented complete resolution of the infectious signs and symptoms and none of them presented late thrombosis of the venous graft. Conclusion: The use of the superficial femoral vein is a good surgical alternative for the treatment of prosthetic infections with minimal venous morbidity of the lower limbs used as venous graft donors. The autogenous venous grafts present good long-term patency and excellent adaptation to the aortoiliofemoral position. 2002 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved Keywords: aorta abdominal, aortic diseases, infection, femoral vein, reoperation, prosthesis failure
Introduction The management of synthetic vascular prosthetic infections has been a constant challenge to vascular surgeons. Several surgical alternatives have been proposed, with mortality rates ranging from 10.0 to 36.0% and lower limb amputation rates ranging from 10.0 to 45.0%, as reported in literature reviews [1, 2]. The treatment most frequently used consists of removal of the infected prosthetic graft and restoration of arterial blood flow to the lower limbs by
Correspondence to: M. A. Cardozo, Rua Marqueˆs do Pombal, 1199/401, 90540-001 Porto Alegre, RS, Brazil. Tel.: +55-51-3372306; fax: +55-51-337-2306; e-mail: [email protected]
304
the extraanatomical route [2, 3]. Successful series have been reported over the last few years, showing the efficiency of deep veins of the lower limbs for autogenous reconstruction in the treatment of prosthetic infection [1, 4–12]. In the present study we report our experience with the use of a superficial femoral vein for reconstruction of the aortoiliofemoral sector in the treatment of infected prosthetic grafts.
Patients From December 1995 to November 1999, twelve patients (11 men and 1 woman) with infected synthetic vascular prosthetic grafts in the aortoiliofemoral sector were submitted to thirteen surgical proCARDIOVASCULAR SURGERY
AUGUST 2002 VOL 10 NO 4
Treatment of infected aortoiliofemoral prosthetic grafts: M. A. Cardozo et al.
cedures for partial or total graft removal and replacement with a superficial femoral vein. The patient age ranged from 40 to 80 years (mean, 61.2 years). Previous arterial restoration surgery was performed due to aortoiliac obstructive diseases in 5 patients, due to an abdominal aorta aneurysm in five, and due to vascular trauma in two (Table 1). One these patients was submitted to correction of a femoral anastomotic pseudoaneurysm six years after implantation of the aortobifemoral prosthesis (case 9). A precoagulated Dacron prosthesis was used in 11 previous operations and an expanded polytetrafluoroethylene prosthesis was used in one. The time elapsed between previous arterial restoration surgery and patient hospitalization with symptoms of prosthetic infection ranged from 16 days to 74 months (mean, 23 months). All patients were admitted with a primary infection of the vascular prosthesis. Signs of sepsis (fever and leukocytosis) were observed in ten cases. Most of the presenting symptoms were located at the level of the groin, but two patients presented with a retroperitoneal abscess. The infections were due to a variety of organisms, with staphylococci being the most frequent (Table 1).
Methods Surgical treatment with partial or total prosthesis removal, restoration of arterial flow with a deep vein from the lower limbs and antibiotic treatment were indicated for patients with a clinical and/or laboratory and/or tomographic diagnosis of infection involving the synthetic vascular graft in the aortoili-
ofemoral sector. The decision about total or partial graft removal was based on clinical signs and symptoms, on computer tomography of the abdomen and on the type of bacteria responsible for the infection. The patients submitted to total graft replacement were the ones who were prostrated, had fever, leukocytosis, and showed a worsening of the infection. Their computer tomography showed involvement of the prosthesis’ body and limbs. They also had gramnegative infections which could also be associated with non-aerobic bacteria. Patency of the lower extremity deep veins was confirmed preoperatively by duplex scan in 11 patients. Two patients were not submitted to this examination because they needed urgent operation. The basic techniques for this operation were described by Clagett et al. [1] in 1993. Intravenous antibiotic therapy is started before the operation and continued until discharge to patient with total graft resection or continued for 6 weeks to patient with partial graft resection. Complete removal of the aortobifemoral prosthetic graft and restoration of arterial flow in situ using two superficial femoral veins with end-to-end anastomosis in the abdominal aorta was performed in three cases (Figure 1). Exchange of a branch of the aortobifemoral prosthetic graft with a superficial femoral vein in situ was performed in six cases. This exchange was performed via extra peritoneal access and dissection of the groin area. Extreme care was taken to avoid exposition and contamination of the remaining prosthesis. In one of these cases simultaneous femorotibial revascularization with a homolateral saphenous vein was required due to associated decompensated distal ischemia. In another patient,
Table 1
Demographic data and presenting symptoms in 12 patients (13 cases)
No
Sex/age
Primary operation
Presenting symptoms
Organisms
1 2a 3 4 5 6
M/70 M/40 M/53 M/58 M/56 F/80
AAA:AF2 PG T: IF PG AIOD: AF2 PG AIOD: AF2 PG AIOD: AF2 PG AAA:AI2 PG
S. epidermidis No growth Enterobacter aerogenes S. aureus+E. coli S. aureus Proteus mirabilis+Bacteroides fragilis
7a
M/49
AIOD: AF2 PG
8 9 10b 11 12b 13
M/67 M/63 M/77 M/68 M/78 M/54
T: IF PG+FP PG AAA: AF2 PG AAA: AF2 PG AIOD: AF2 PG AAA: AF2 PG AAA: AF2 PG
Draining groin sinus fever+leukocytosis Femoral anastomotic rupture fever+leukocytosis Draining groin sinus (bilateral) fever+leukocytosis Groin abscess fever+leukocytosis Draining groin sinus fever+leukocytosis Anastomotic aortic aneurysm, Retroperitoneal abscess fever+leukocytoses Draining groin sinus, femoral anastomotic rupture fever+leukocitosis Draining groin sinus fever+leukocytosis Draining groin sinus Draining groin sinus Weigth loss Retroperitoneal abscess fever+leukocytosis Draining groin fistula Anastomotic femoral aneurysm, perigraft mass fever+leukocytosis
S. aureus S. aureus S. epidermidis No growth S. aureus No growth (gram-positive cocci) No growth
AAA, abdominal aortic aneurysm; AF2, aortobifemoral; AI2, aortobiiliac; AIOD, aortoiliac occlusive disease; F, female; Ftib, femorotibial; IF, iliofemoral; M, male; PG, prosthetic graft; S, Staphylococcus; T, trauma; VG, venous graft. a Emergency cases. b The same patient.
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two superficial femoral veins were used and the distal anastomosis was performed in the popliteal artery above the knee (case 7). Exchange of the two branches of the aortobifemoral prosthetic graft with a superficial femoral vein, with an 8-month interval between operations, was performed in one patient previously submitted to various femoral catheterizations through the prosthesis for the diagnosis and treatment of obstructive coronary disease (cases 10 and 12). The body of the aortofemural bypass graft was left in place after the second procedure. This patient never presented clinical symptoms of sepsis and the computer tomographies did not show involvement of the prosthesis’ body, neither before nor after surgery. The infection of the other graft limb took place around 25 days after coronary angioplasty by femoral catheterism via prosthesis. The surgical technique which was used for the exchange of both branches was the same which was previously described for the partial graft replacement cases. Complete removal of the iliofemoral prosthetic graft and revascularization with a superficial femoral vein in situ was performed in two cases and one of them was submitted to removal of an associated femoropopliteal prosthetic graft without requiring distal revascularization (Table 2). Angiography was performed in four patients before discharge for the control and documentation of selected cases. After discharge, all patients were observed at 6-month intervals. Follow-up included clinical vascular examination and duplex scan examination of the reconstruction and of the donor graft limb.
Results All surviving patients presented complete resolution of the infectious picture and none of them presented late thrombosis of the venous graft. The angiographic examination performed on four patients was considered to be satisfactory in all cases (Figure 2). No clinically significant lower limb edema was
observed in any patient after dissection of the superficial femoral vein. Two thigh amputations were performed (limb salvage rate of 87.5%). One patient who had femoropopliteal and distal occlusion of the left leg under control before surgery presented serious ischemic symptoms right after the surgery. These symptoms did not show sign of improvement after clinical treatment; they led to the amputation of the leg on the second day due to irreversible ischemia. No attempt at distal revascularization was made due to the persistence of the septic picture and the poor clinical condition of the patient. At the time of amputation the venous graft was patent and ischemia was attributed to thrombosis of the distal microcirculation during arterial clamping (case 6). Another patient presented pseudoaneurysm of the anastomosis between the superficial femoral veins. The pseudoaneurysm was resected and the venous graft presented thrombosis with irreversible ischemia of the lower limb on the 47th postoperative day. This patient had severe chronic arterial obstructive disease. The thrombosis of the venous graft was due to a poor runoff (Table 2). The overall surgical mortality was 15.3%. One patient submitted to complete removal of the aortobifemoral prosthetic graft and reconstruction with two femoral veins died two days after operation due to sepsis and multiple organ failure. Another patient submitted to complete removal of the aortobiiliac prosthetic graft and reconstruction with superficial femoral veins died of sepsis and hemorrhage due to suture dehiscence in the anastomosis of the proximal aorta on the eighth day after operation (Table 2). Patient follow-up ranged from 6 to 65 months (mean, 22 months). The data of the present study have been computed up to May 2000. There was no mortality related to the surgical procedure during follow-up. One patient was admitted during the 13th follow-up month with a trophic lesion of the heel that did not respond satisfactorily to treatment, requiring thigh amputation in spite of the venous grafts being patent at the time of amputation (Table 2). Duplex scan of the venous graft was performed in 10 cases at 6 month intervals after surgery and did not show signs of aneurysmatic dilatation or focal stenosis between the 6th and 65th month of followup (Figure 3). No edema or signs of chronic venous insufficiency were observed in the lower limbs used as self-graft donors, and duplex scan examination of these limbs did not reveal deep venous thrombosis or important reflux of venous circulation during follow-up (Figure 4a and b).
Figure 1 Intraoperative photograph of the aortobifemoral restoration with superficial femoral veins (case 4).
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Treatment of infected aortoiliofemoral prosthetic grafts: M. A. Cardozo et al. Table 2 Methods of repair and clinical outcome in 12 patients (13 cases) No
Primary operation
Repair
Clinical outcome
1 2a 3 4 5
AF2 PG IF PG AF2 PG AF2 PG AF2 PG
AF1 DVG (in situ) IF DVG (in situ) AF2 DVG (in situ) AF2 DVG (in situ) AF1 DVG (in situ)+Ftib VHG
6 7a 8 9
AI2 PG AF2 PG IF PG+FP PG AF2 PG
AF2 DVG (in situ) AF1 DVG (in situ) IF DVG (in situ) AF1 DVG (in situ)
10b 11 12b 13
AF2 AF2 AF2 AF2
AF1 AF1 AF1 AF1
Alive and well (65 months) Alive and well (40 months) 2 days death (sepsis) Alive and well (36 months) ABA 13 months after operation (lost after 21 months) 8 days death (sepsis+hemorrhage) 47 days ABA (thrombosis) Alive and well (25 months) Died of myocardial infarction after 10 months Alive and well (13 months) Alive and well (8 months) Alive and well (6 months) Alive and well (6 months)
PG PG PG PG
DVG DVG DVG DVG
(in (in (in (in
situ) situ) situ) situ)
ABA, above-knee amputation; AF1, aortounifemoral; AF2, aortobifemoral; AI2, aortobiiliac; DVG, deep vein graft; FP, femoropopliteal; Ftib, femorotibial; IF, iliofemoral; PG, prosthetic graft; VHG, venous homograft. a Emergency cases. b The same patient.
Figure 3 Duplex scan of the aortobifemoral restoration with superficial femoral veins, performed during the 36th postoperative month, demonstrating patency of the anastomoses.
Discussion
Figure 2 Postoperative angiography of an aortobifemoral restoration with superficial femoral veins (case 4).
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The conduct most commonly adopted for cases of synthetic vascular prosthetic infection in the aortoiliofemoral sector is extranatomical revascularization through areas not involved by infection and removal of the aortic prosthetic graft. Mortality varies around 19.4% and the amputation rate is about 10.5%, as reported in a review by Clagett et al. [1]. The most feared early complications of this surgical strategy are infection of the extra-anatomical bridge (16.0% of cases) and dehiscence of the aortic stump (8.5% of cases) [1]. On a medium- and long-term basis, thrombosis of the extra-anatomical graft may be 307
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Figure 4 Photograph taken during the 36th month of follow-up showing the absence of edema of the lower limbs after dissection of the superficial femoral veins used for aortobifemoral reconstruction (case 4) (a) and venous duplex scan of a lower limb performed during the 36th postoperative month showing the absence of deep thrombosis and the patency of the tibial and popliteal veins below the knee (case 4) (b).
catastrophic since it frequently leads to the need for major amputations. In patients with severe obstructive vascular disease, the axillopopliteal and axillofemoral bridges have presented a 43.0% rate of primary patency over a period of three years, with one 308
third of all survivors eventually requiring major amputation [13]. Dissatisfaction with these results has led several surgeons to consider surgical alternatives such as in situ reconstruction with autologous deeps veins from the lower limbs [1, 4–12, 14]. The use of autogenous material in combination with antibiotic treatment is an effective strategy for the control and eradication of infection. In 1979, Ehrenfeld et al. [15] demonstrated the resistance of endarterectomized aortoiliofemoral arterial segments and of saphenous veins as arterial substitutes after removal of infected prostheses. However, the medium- and long-term results obtained with these arterial substitutes in the aortoiliofemoral position present high rates of focal stenosis and thrombosis due to progressive neointimal hyperplasia [1, 16, 17]. In 1991, Fokin et al. [4] reported on a series of 12 patients in whom deep veins from the lower limbs were used for the treatment of infected vascular prostheses in the inguinal region. In 1993, Clagett et al. [1] demonstrated that the superficial femoral veins are less susceptible to late degeneration and to focal stenosis and, by being of wider diameter, are better adapted to the aortoiliofemoral position than saphenous veins. They demonstrated 100% patency for superficial femoral veins and 36% patency for saphenous veins after two years of follow-up. Nevelsteen et al. [6], after treating 15 patients with vascular prosthetic infection using deep veins from the lower limbs, also reported promising results. Clagett et al. [1] pointed out that for a successful reconstruction of arterial flow it is necessary to have an autogenous venous graft of wide caliber, with no signs of previous disease. During preoperative evaluation, they recommend duplex scan study of veins from the lower limbs. Fortunately, the patients in our series who were not submitted to duplex scan because of the urgency of the procedure had good quality superficial femoral veins. We observed no clinically significant edema in none of the lower limbs used as donors of the autogenous venous graft. The duplex scan of these limbs performed during the late postoperative period did not reveal deep venous thrombosis or important reflux of the venous circulation. No patient developed clinical signs of chronic venous stasis. This observation has also been reported by authors who utilized deep veins of the lower limbs as peripheral arterial substitutes and especially femoropopliteal shunts [18–22]. Recently, Wells et al. [23] studied 86 lower limbs of 61 patients treated with the superficial femoral vein removed for use in aortoiliofemoral shunts after removal of the infected prosthetic graft, in a femoropopliteal shunt or in major venous reconstruction. Patient follow-up ranged from three to 37 months. No patient presented signs of chronic venous insufficiency or limping of venous origin and the results were not CARDIOVASCULAR SURGERY
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influenced by the presence or absence of the ipsilateral magna saphenous vein. Major amputations of the lower limbs related to the surgical procedure were performed in two cases, with a limb salvage index of 87.5%. Fokin et al. [4] reported two major amputations in their patients. In two different series, Clagett et al. [1, 7] reported a 10.0% and a 4.8% amputation rate in patients with prosthetic infection treated with the deep veins from the lower limbs for the reconstruction of the aortofemoral sector. Nevelsteen et al. [6] using the same technique for the treatment of 15 patients, performed a major amputation due to distal obstructive arterial disease and the index of lower limb salvage was 96.0%. Two patients with massive prosthetic infections caused by Gram-negative bacteria kept their sepsis and died due to multiple organ failure in one case, and hemorrhage caused by dehiscence of aortovenous anastomosis suture in the other. Hemorrhage in this second patient probably happened because of the virulence of the infecting organism as the aortic stump was adequately debrided at the time of graft replacement. Gram-negative bacteria, Pseudomonas sp in particular, have the ability to produce proteolytic enzymes (proteases) and the infections are frequently associated with sepsis, tissue necrosis, dehiscence of the anastomosis and rupture of the arteries involved [24–26]. Franke and Voit [8] reported two deaths due to dehiscence of the aortovenous anastomosis in infections caused by Pseudomonas aeruginosa among seven patients. Clagett et al. [1] and Nevelsteen et al. [6] reported a successful outcome in two and three cases, respectively, of vascular prosthetic infection caused by P. aeruginosa treated with a superficial femoral vein in situ. The mortality rate reported by these authors was 7.0% [6] and 9.6% [7]. All patients presented prosthetic infection associated with erosion or an aortoenteric fistula. We did not treat any patient with this condition. In our series, the overall mortality rate was 15.3%. Although the number of patients was not too high and our group was heterogeneous in terms of surgery performed, this general mortality rate has also been published by other authors when they speak about mortality [1, 6, 7]. All survivors presented complete cure of the infection, a fact demonstrating the efficacy of the technique in eradicating the infection and confirming its high cure rate, also observed in other series reported in the literature [1, 4–12]. In addition, this result justifies the partial resection of the prosthetic graft in cases in which the microorganism causing the infection is of low aggressiveness (Staphylococcus epidermidis) or of moderate aggressiveness (Staphylococcus aureus) and in which computed tomography demonstrates the separate involvement of only one branch of the prosthetic graft. CARDIOVASCULAR SURGERY
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The duplex scan of the venous graft did not show signs of aneurysmatic dilatations or focal stenosis between the 6th and 65th month of follow-up in this series. Similar observations were reported by Clagett et al. [7]. The same authors reported an 83.0% rate of primary patency and a 100.0% rate of secondary patency over a five-year follow-up. We did not observe any case of graft thrombosis during followup.
Conclusions The use of the superficial femoral vein is a good surgical alternative for the treatment of synthetic vascular prosthetic graft infection. The course of these infections is significantly affected by the extent of prosthetic graft involvement and by the aggressiveness of the microorganisms involved. The technique has an excellent cure rate. The venous grafts show good long-term patency and an excellent adaptation to the aortoiliofemoral position, with minimal venous morbidity of the lower limbs used as venous graft donors.
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Paper accepted 28 February 2002
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