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Extra-anatomic autologous reconstruction with hepatic-iliac artery bypass graft for aortic endograft infection

2013; Elsevier BV; Volume: 61; Issue: 1 Linguagem: Inglês

10.1016/j.jvs.2013.08.091

1097-6809

Adelaide Buora, M Floriani, L. Gabrielli,

Vascular Procedures and Complications

We present a new intra-abdominal extra-anatomic bypass graft for a 64-year-old man treated with an abdominal aortic endograft and with signs of endograft infection. We performed surgical removal of the endograft and intra-abdominal extra-anatomic reconstruction of a hepatic-to-right external iliac artery bypass with autologous superficial femoral vein and a crossover graft between the right and left external iliac artery with the great saphenous vein. The later occlusion of the saphenous vein graft led us to perform a femoral-femoral prosthetic crossover. At 42 months from the intervention, the patient was in good health, and duplex scanning confirmed the patency of all grafts. We present a new intra-abdominal extra-anatomic bypass graft for a 64-year-old man treated with an abdominal aortic endograft and with signs of endograft infection. We performed surgical removal of the endograft and intra-abdominal extra-anatomic reconstruction of a hepatic-to-right external iliac artery bypass with autologous superficial femoral vein and a crossover graft between the right and left external iliac artery with the great saphenous vein. The later occlusion of the saphenous vein graft led us to perform a femoral-femoral prosthetic crossover. At 42 months from the intervention, the patient was in good health, and duplex scanning confirmed the patency of all grafts. Graft infection is a rare but serious complication that can occur after open or endovascular repair of an abdominal aortic aneurysm. The frequency of aortoiliac stent graft infection is estimated to be between 0.4% and 4%.1Heyer K.S. Modi P. Morasch M.D. Matsumura J.S. Kibbe M.R. Pearce W.H. et al.Secondary infections of thoracic and abdominal aortic endografts.J Vasc Interv Radiol. 2009; 20: 173-179Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar, 2Veraldi G.F. Genco B. Minicozzi A. Zecchinelli M.P. Segattini C. Momo R.E. et al.Abdominal aortic endograft infection. Report of two cases and review of the literature.Chir Ital. 2009; 61: 61-66PubMed Google Scholar, 3Ducasse E. Calisti A. Speziale F. Rizzo L. Misuraca M. Fiorani P. Aortoiliac stent graft infection: current problems and management.Ann Vasc Surg. 2004; 18: 521-526Abstract Full Text Full Text PDF PubMed Scopus (168) Google Scholar Graft infection-related mortality is reported to be between 18% and 50%.3Ducasse E. Calisti A. Speziale F. Rizzo L. Misuraca M. Fiorani P. Aortoiliac stent graft infection: current problems and management.Ann Vasc Surg. 2004; 18: 521-526Abstract Full Text Full Text PDF PubMed Scopus (168) Google Scholar, 4Sharif M.A. Lee B. Lau L.L. Ellis P.K. Collins A.J. Blair P.H. et al.Prosthetic stent graft infection after endovascular abdominal aortic aneurysm repair.J Vasc Surg. 2007; 46: 442-448Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar, 5Cernohorsky P. Reijnen M.P. Tielliu I.F. van Sterkenburg S.M. van den Dungen J.A. Zeebregts C.J. The relevance of aortic endograft prosthetic infection.J Vasc Surg. 2011; 54: 327-333Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar The general consensus is that infected graft material should be completely removed and replaced with an in situ reconstruction or an extra-anatomic bypass graft. We describe a patient who we treated with an innovative approach with intermediate characteristics between an in situ reconstruction and an extra-anatomic bypass graft. The patient gave consent for the publication of his data. A 64-year-old man affected by Stevens-Johnson syndrome and multiple allergies to antibiotics underwent in September 2009 endovascular repair of a right aortoiliac aneurysm in another hospital. In December 2009, a left common femoral artery pseudoaneurysm, that was apparently not infected and caused by arterial suture dehiscence, was observed and repaired. In February 2010, the patient developed signs of systemic sepsis with diffuse pain, weight loss, and persistent fever, for which he was admitted to the Division of Internal Medicine of our hospital. An abdominal computed tomography (CT) scan showed periprosthetic fluid and air within the aneurysm sac (Fig 1), and a labeled leukocyte scintigraphy confirmed the suspicion that the graft was infected. The patient was scheduled for surgical removal of the infected graft and in situ reconstruction with autologous vein. Median laparotomy and surgical exposure of the aortoiliac segments were performed, and the right superficial femoral vein and left saphenous vein were explanted. Exposure of the suprarenal segment of the aorta was attempted, without success, due to retroperitoneal inflammatory fibrosis involving the duodenum and making it inseparable from the aorta. We observed a small perforation of duodenal wall, probably due to the attempted cleavage, which was repaired with a double-layer suture. We clamped the supraceliac aorta and the iliac bifurcations. When the aneurysm sac was opened we observed a collection of pus that was sampled for cultural examination. The 30-mm-diameter Endurant graft (Medtronic, Minneapolis, Minn) was removed and sent for cultural examination. In consideration of the large infrarenal aortic diameter (26 mm), the anastomosis with the superficial femoral vein, even using a coaxial double vein graft technique, did not seem feasible. We therefore sutured the aortic stump with 2-0 Prolene (Ethicon, Somerville, NJ). The retroperitoneal space was carefully debrided and rinsed with iodinated solution. We decided to proceed with an intra-abdominal reconstruction to avoid the higher risk of reinfection connected with an axillobifemoral prosthetic bypass. The difficulty of performing an end-to-side anastomosis in the suprarenal aortic segment and the resulting contiguity of the duodenal dehiscence to the graft dissuaded us to use the aorta as the source of inflow. We therefore decided to use the common hepatic artery, which appeared to have an appropriate caliber and flow, as the source of inflow. We performed an end-to-side anastomosis between the common hepatic artery and the superficial femoral vein, with right paracolic retroperitoneal tunnelization of the venous segment and distal end-to-end anastomosis with the right external iliac artery (the common iliac artery was aneurysmatic and the internal iliac was occluded). The great saphenous vein was anastomosed end-to-side with the grafted superficial femoral vein and then positioned in the submesenteric left retrocolic retroperitoneal space and distally anastomosed with the left external iliac artery. The duplex scan control showed triphasic blood flow in the femoral vein graft at declamping, whereas flow in the saphenous vein segment had a lower diphasic signal. A pedunculated flap of omentum was transposed into retroperitoneal position and sutured to the aortic stump and to the duodenum. The patient's postoperative course was unremarkable. Cultures of the intraoperatively collected specimens showed a Staphylococcus aureus infection, for which an antibiogram-guided treatment with amoxicillin and clavulanate was started and continued for 60 days. The patient was discharged on postoperative day 18 with compressive stockings. At 2 months after surgery, a CT scan showed the resolution of all signs of abdominal infection, the patency of the right femoral vein graft, and the occlusion of the saphenous cross-over segment (Fig 2). The patient showed a residual claudication of about 100 meters, and the ankle-brachial index on left anterior tibial artery decreased from 1 to 0.4. At 3 months after the first intervention, we decided to perform a femoral-to-femoral right-to-left bypass using an 8-mm Dacron (DuPont, Wilmington, Del) silver graft (Fig 3). CT scans 6, 12, and 24 months later confirmed the patency of all bypass grafts and no signs of infection. At 42 months from the first intervention, the patient was in good health, with no leg edema, and anterior tibial artery pulses were bilaterally present. Endograft infection is a rare event but represents a challenging management problem in aortic surgery. Some authors suggest conservative treatment of the infection in selected patients,6Hulin S.J. Morris G.E. Aortic endograft infection: open surgical management with endograft preservation.Eur J Vasc Endovasc Surg. 2007; 34: 191-193Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 7Blanch M. Berjón J. Vila R. Simeon J.M. Romera A. Riera S. et al.The management of aortic stent-graft infection: endograft removal versus conservative treatment.Ann Vasc Surg. 2010; 24: 554.e1-554.e5Abstract Full Text Full Text PDF Scopus (31) Google Scholar, 8Jamieson R.W. Burns P.J. Dawson A.R. Fraser S.C.A. Aortic graft preservation by debridement and omental wrapping.Ann Vasc Surg. 2012; 26: 423.e1-423.e4Abstract Full Text Full Text PDF Scopus (5) Google Scholar but conservative measures usually are associated with poor outcomes.9Saleem B.R. Meerwaldt R. Tielliu I.F.J. Verhoeven E.L. van den Dungen J.J. Zeebregts C.J. Conservative treatment of vascular prosthetic graft infection is associated with high mortality.Am J Surg. 2010; 200: 47-52Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar The most widely accepted standard intervention is complete graft excision and local debridement, followed by the suture of the aortic stump and extra-anatomic revascularization through an axillobifemoral bypass graft. This procedure is definitely rational and relatively simple to perform but is not free of risk for severe complications, such as occlusion, reinfection of the prosthetic graft (especially in the setting of bacteremia), and rupture of the aortic suture line. Extra-anatomic reconstructions using autologous vein do not seem to be feasible. This concern has led an increasing number of surgeons to consider an in situ reconstruction, using a Dacron or polytetrafluoroethylene prosthesis, rifampicin-bonded or rifampicin-gelatin grafts,10Uchida N. Katayama A. Tamura K. Miwa S. Masatsugu K. Sueda T. In situ replacement for mycotic aneurysms on the thoracic and abdominal aorta using rifampicin-bonded grafting and omental pedicle grafting.Ann Thorac Surg. 2012; 93: 438-442Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 11Töpel I. Audebert F. Betz T. Steinbauer M.G. Microbial spectrum and primary resistance to rifampicin in infectious complications in vascular surgery: limits to the use of rifampicin-bonded prosthetic grafts.Angiology. 2010; 61: 423-426Crossref PubMed Scopus (24) Google Scholar human cryopreserved aorta, or treated heterologous grafts.12Ali A.T. Modrall G. Hocking J. Valentine R.J. Spencer H. Eidt J.F. et al.Long-term results of the treatment of aortic graft infection by in situ replacement with femoral popliteal vein grafts.J Vasc Surg. 2009; 50: 30-39Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar, 13Bown K.E. Heyer K. Rodriguez H. Eskandari M.K. Pearce W.H. Morasch M.D. Arterial reconstruction with cryopreserved human allografts in the setting of infection: a single-center experience with midterm follow-up.J Vasc Surg. 2009; 49: 660-666Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar Autologous vein for in situ reconstruction is considered the most effective means of avoiding reinfections14O'Connor S. Andrew P. Batt M. Becquemin J.P. A systematic review and meta-analysis of treatments for aortic graft infection.J Vasc Surg. 2006; 44: 38-45Abstract Full Text Full Text PDF PubMed Scopus (257) Google Scholar; the superficial femoral vein has favorable mechanical properties, with a 90% to 95% long-term patency.15Beck A.V. Murphy E.H. Hocking J.A. Timaran C.H. Arko F.R. Clagett G.P. Aortic reconstruction with femoral-popliteal vein: graft stenosis incidence, risk and reinterventions.J Vasc Surg. 2008; 47: 36-44Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 16Batt M. Jean-Baptiste E. O'Connor S. Bouillanne P.J. Haudebourg P. Hassen-Khodja R. et al.In-situ revascularization for patients with aortic graft infection: a single center experience with silver coated polyester grafts.Eur J Vasc Endovasc Surg. 2008; 36: 182-188Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar Removal of the superficial femoral vein is normally well tolerated, with rare cases of persistent lower limb edema requiring long-term compression. Considering the patient's situation—presence of duodenal dehiscence and a short and large aortic neck below the renal arteries—we believe that our solution should be considered in similar cases. Access to the hepatic artery is relatively easy, the vessel usually has a good caliber, is spared from significant atheromatosis, and can guarantee a good inflow. The position of the graft in the right paracolic space keeps it separated from the septic focus and from the possible consequences of a duodenal dehiscence. The same can hold true for the segment of the crossover graft running below the mesentery. We used the great saphenous vein as the crossover graft to avoid the surgical trauma of a bilateral femoral retrieval and because the saphenous vein seemed of good quality. We believe that early occlusion of the saphenous graft is occasional, probably due to an error in anastomotic technique or a low flow state and, therefore, not relevant in the choice of a mixed autologous solution. We propose an alternative intra-abdominal reconstruction, based on an inflow from the hepatic artery, for patients with severe endovascular graft infection with duodenal fistula or marked discrepancy between the diameters of the infrarenal aorta and the venous graft. In the absence of these major risk factors, we are in favor of an in situ reconstruction from the aortic neck.