Surgical treatment of infected aortic grafts
An infection of an aortic prosthesis is a severe condition with high morbidity and mortality rates. Surgical treatment of an infected aortic graft or infected aortic stent-graft focuses on treatment of the infection and maintaining or restoring perfusion of the lower limbs. Over the years various reconstruction options have been introduced, each claiming to be the most successful in securing lower limb perfusion. Consensus about the optimum treatment strategy is lacking. The frail patient population and the relative rarity of the disease limits research on this topic which is an important reason for this lack of consensus. In order to determine which of the various treatment options is the most suitable to treat aortic graft infections, this systematic review was conducted of the available literature of the last 20 years. The search strategy and data collection were based on the guidelines of the Meta-analysis Of Observational Studies in Epidemiology (MOOSE). Appropriate inclusion and exclusion criteria were defined. A total of 862 possibly relevant papers were identified. After applying the in- and exclusion, data on mortality, morbidity and complications were extracted from a total of 93 papers. This review covers the various surgical treatment options available in the treatment of infected aortic (stent) grafts. Strategies concerning graft excision are discussed as are the advantages and disadvantages of the extra-anatomic reconstruction and its counterpart, the in situ reconstruction (using antibiotic-impregnated grafts, autologous vein grafts, fresh or cryopreserved allografts, and silver impregnated grafts). Available evidence was summarized and used to construct a clinical decision flowchart. All reconstruction options seem to have their pros and cons, and all have their use in specific situations. The treatment of infected aortic grafts must therefore be tailor-made.
Available from: Paul Berger
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ABSTRACT: Silver-coated grafts are designed to prevent vascular graft infections. Silver is a safe element but toxic effects have been reported. We describe two cases of possible localized argyria after silver graft implantation.
Two patients presented with perigraft groin collections after implantation of silver grafts. During reoperation, an ashen-grey necrotic substance was seen surrounding the grafts. The grafts were explanted and lower limb perfusion restored. Cultures were negative and both patients had uneventful recoveries.
Our cases are highly suggestive of a possible unique adverse effect: a combination of localized silver toxicity and neutrophilic mediated tissue destruction.
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We report a 52-year-old male presenting with a graft-appendiceal fistula four years after placement of an aorto-bifemoral Dacron prosthesis.
After appendectomy and total graft removal, the patient was treated with an in-situ repair using a rifampicin-silver graft. This kind of repair has only been reported in an animal study.
This infected aortic graft was treated successfully with a rifampicin-silver graft with a follow-up of 15 months without complications.
In-situ repair of a graft-appendiceal fistula with a rifampicin-silver graft seems a promising strategy. The long-term outcome needs to be studied.
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ABSTRACT: The clinical dilemma in suspected aortic graft infection (AGI) is how to noninvasively obtain a reliable proof of infection. In addition to confirming the presence of infection, obtaining information regarding the extent of infection to select a proper strategy for reoperation is also necessary. Therefore, developing a more reliable noninvasive physiologic approach to detect infected prostheses is required. (18)F-fluorodeoxyglucose positron emission tomography scanning ((18)F-FDG PET) has been suggested to have a pivotal role in the detection of AGI. In this study, we assessed the contribution of two (semi) quantitative parameters-maximal standardized uptake value (SUVmax) and tissue-to-background ratio (TBR)-and of two visual parameters-fluorodeoxyglucose (FDG) distribution patterns and visual grading scale-in the final confirmation of the diagnosis of AGI.
Patients with a central aortic prosthetic graft and symptoms clinically suggestive of AGI were gathered from a prospectively maintained database. Included were those who underwent (18)F-FDG PET scanning combined with computed tomography angiography and in whom periprosthetic samples were taken at some stage in the diagnostic process. AGI was considered proven in case of a positive culture and compared with a group with negative cultures. Positive predictive values (PPVs) and negative predictive values (NPVs) were calculated. Receiver operating characteristics curves were used to assess the ability of SUVmax and TBR to identify the presence and absence of AGI (ie, accuracy).
In 37 of 77 patients with suspected AGI, (18)FDG-PET and perigraft material for culturing was obtained. The tissue culture was positive in 21 of these 37 patients (56.7%). Mean ± standard deviation SUVmax for proven infection was 8.1 ± 3.7 (range, 3.6-18.5) and TBR was 5.9 ± 2.7 (range, 1.7-13.0). The area under the curve for SUVmax was 0.78 (95% confidence interval, 0.63-0.93). A cutoff value of 8 yielded a PPV of 80% and a NPV of 54%. The area under the curve for TBR was 0.70 (95% confidence interval, 0.52-0.87). A cutoff value of 6 yielded a PPV of 73% and NPV of 52%. The PPVs for the visual grading scale and (18)F-FDG distribution patterns were 75% and 61%, respectively; the NPVs were 77% and 67%, respectively.
Our study, performed in a small sample of patients suspected of AGI, showed that the diagnostic abilities of quantitative and visual (18)F-FDG PET parameters are modest.
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