Clinical Challenges in Vascular Surgery: Aortic Graft Infections

Behind The Knife: The Surgery Podcast

Science, Health & Fitness, Medicine, Education

4.8 • 1.4K Ratings

🗓️ 13 July 2023

⏱️ 28 minutes

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Summary

In this episode of Behind the Knife the vascular surgery subspecialty team discusses a case of an infected endovascular aortic graft. Although rare, aortic graft infections remain a devastating complication. What options do you have to fix this problem? In this episode, we will cover the who is at risk of this, how they present, and what options you have to fix it.
Hosts:
Dr. Bobby Beaulieu is an Assistant Professor of Vascular Surgery at the University of Michigan
Dr. Frank Davis is an Assistant Professor of Vascular Surgery at the University of Michigan
Dr. David Schechtman is a Vascular Surgery Fellow at the University of Michigan
Dr. Drew Braet is a PGY-3 Integrated Vascular Surgery Resident at the University of Michigan

Learning Objectives
· Understand the incidence of and the relevant risk factors for aortic graft infections
· Review the spectrum of presenting symptoms and relevant workup for aortic graft infections
· Understand surgical treatment options including options for in-situ bypass and extra-anatomic bypass
· Review the different conduits that can be used for in-situ and extra-anatomic reconstruction
· Discuss relevant post-operative considerations for patients undergoing operative intervention for aortic graft infection

References

· Chiesa R, Astore D, Frigerio S, Garriboli L, Piccolo G, Castellano R, Scalamogna M, Odero A, Pirrelli S, Biasi G, Mingazzini P, Biglioli P, Polvani G, Guarino A, Agrifoglio G, Tori A, Spina G. Vascular prosthetic graft infection: epidemiology, bacteriology, pathogenesis and treatment. Acta Chir Belg. 2002 Aug;102(4):238-47. doi: 10.1080/00015458.2002.11679305. PMID: 12244902.
· Bisdas T, Bredt M, Pichlmaier M, Aper T, Wilhelmi M, Bisdas S, Haverich A, Teebken OE. Eight-year experience with cryopreserved arterial homografts for the in situ reconstruction of abdominal aortic infections. J Vasc Surg. 2010 Aug;52(2):323-30. doi: 10.1016/j.jvs.2010.02.277. Epub 2010 Jun 8. PMID: 20570473.
· PereraG. B.FujitaniR. M.KubaskaS. M.2006Aortic graft infection: Update on Management and Treatment Options.Vasc Endovascular Surg, 401Jan), 1101538-5744
· Hallett J., Marshall D.M., Petterson T.M., et. al.: Graft-related complications after abdominal aortic aneurysm repair: Population-based experience. J Vasc Surg 1977; 25: pp. 277-284.
· Kieffer E, Sabatier J, Plissonnier D, Knosalla C. Prosthetic graft infection after descending thoracic/ thoracoabdominal aortic aneurysmectomy: management with in situ arterial allografts. J Vasc Surg. 2001 Apr;33(4):671-8. doi: 10.1067/mva.2001.112314. PMID: 11296316.
· Gutowski P. Zakazenie aortalno-biodrowej protezy naczyniowej jako problem diagnostyczny i leczniczy [Aortoiliac graft infection as a diagnostic and treatment problem]. Ann Acad Med Stetin. 1998;Suppl 41:1-72. Polish. PMID: 9766086.
· Capoccia L, Mestres G, Riambau V. Current technology for the treatment of infection following abdominal aortic aneurysm (AAA) fixation by endovascular repair (EVAR). J Cardiovasc Surg (Torino). 2014;55:381–389.
· Setacci C, Chisci E, Setacci F, Ercolini L, de Donato G, Troisi N, Galzerano G, Michelagnoli S. How To Diagnose and Manage Infected Endografts after Endovascular Aneurysm Repair. Aorta (Stamford). 2014 Dec 1;2(6):255-64. doi: 10.12945/j.aorta.2014.14-036. PMID: 26798744; PMCID: PMC4682678.
· Reinders Folmer E.I., Von Meijenfeldt G.C.I., Van der Laan M.J., Glaudemans A.W.J.M., Slart R.H.J.A., Saleem B.R., Zeebregts C.J. Diagnostic Imaging in Vascular Graft Infection: A Systematic Review and Meta-Analysis. Eur. J. Vasc. Endovasc. Surg. 2018;56:719–729. doi: 10.1016/j.ejvs.2018.07.010.
· Rafailidis V., Partovi S., Dikkes A., Nakamoto D.A., Azar N., Staub D. Evolving clinical applications of contrast-enhanced ultrasound (CEUS) in the abdominal aorta. Cardiovasc. Diagn. Ther. 2018;8:S118–S130. doi: 10.21037/cdt.2017.09.09.
· Hayes P.D., Nasim A., London N.J., et. al.: In situ replacement of infected aortic grafts with rifampicin-bonded prostheses: The Leicester experience (1992 to 1998). J Vasc Surg 1999; 30: pp. 92-98.
· Oderich GS, Bower TC, Hofer J, Kalra M, Duncan AA, Wilson JW, Cha S, Gloviczki P. In situ rifampin-soaked grafts with omental coverage and antibiotic suppression are durable with low reinfection rates in patients with aortic graft enteric erosion or fistula. J Vasc Surg. 2011 Jan;53(1):99-106, 107.e1-7; discussion 106-7. doi: 10.1016/j.jvs.2010.08.018. PMID: 21184932.
· Bisdas T., Bredt M., Pichlmaier M., et. al.: Eight-year experience with cryopreserved arterial homografts for the in situ reconstruction of abdominal aortic infections. J Vasc Surg 2010; 52: pp. 323-330.
· O'Hara P.J., Hertzer N.R., Beven E.G., et. al.: Surgical management of infected abdominal aortic grafts: Review of a 25-year experience. J Vasc Surg 1986; 3: pp. 725-731.
· Quiñones-Baldrich WJ, Hernandez JJ, Moore WS. Long-term Results Following Surgical Management of Aortic Graft Infection. Arch Surg. 1991;126(4):507–511. doi:10.1001/archsurg.1991.01410280111018
· Kieffer E., Gomes D., Chieche L., et. al.: Allograft replacement for infrarenal aortic graft infection: Early and late results in 179 patients. J Vasc Surg 2004; 39: pp. 1009-1017.
· Zhou W., Lin P.H., Bush R.L., et. al.: In situ reconstruction with cryopreserved arterial allografts for management of mycotic aneurysms or aortic prosthetic graft infections: A multi-institutional experience. Texas Heart Institute J 2006; 33: pp. 14-18. 2006
· Ali AT, Modrall JG, Hocking J, Valentine RJ, Spencer H, Eidt JF, Clagett GP. Long-term results of the treatment of aortic graft infection by in situ replacement with femoral popliteal vein grafts. J Vasc Surg. 2009 Jul;50(1):30-9. doi: 10.1016/j.jvs.2009.01.008. PMID: 19563952.

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Transcript

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0:00.0	Behind the Night, the surgery podcast, relevant and engaging content designed to help you dominate the day.
0:13.0	This is Drew Bray, you're along with Bobby Bullew, Frank Davis, and David Checkman.
0:26.0	We are your behind-the-knife sub-specialty team and vascular surgery from the University of Michigan.
0:31.0	And we're looking forward to discussing interesting vascular surgery cases and papers with you all.
0:36.0	Today we have a very challenging case of an infected aortic graft.
0:40.0	This is somewhat the vein of our existence in vascular surgery because there really are no simple solutions to aortic graft infections.
0:47.0	Historically treatment for this was quite morbid and a thoughtful approach and thorough understanding of the different options is necessary to minimize the risks.
0:55.0	In vascular surgery we use a lot of different grafts across the entire body and from time to time we see infections of all of these.
1:03.0	We're going to begin with a review of some of the basics of aortic graft infections, discuss risk factors, patient presentation and work up.
1:10.0	And then we'll go into our case and discuss the different treatment options with a review of the data and some thoughts on our general approach to these patients.
1:18.0	So Frank, why don't you kick us off with a bit of an introduction. Why do we care not infected aortic grafts?
1:23.0	Thanks Drew and I appreciate bringing up this topic and as we all know aortic graft infections are one of the most devastating complications we can see here in vascular surgery.
1:32.0	And historically these were aortic infections in general and the primary aortic infections were usually caused by such things as salmonella or syphilis.
1:41.0	But as we in vascular surgery have started to reconstruct their arterial system and mainly the aorta with open reconstructions we're seeing more and more aortic graft infections from our open reconstructions or even our end of vascular reconstructions.
1:52.0	And the true incidence of graft infections from either an open reconstruction or an end of vascular reconstruction is really difficult to establish because of differences in both the definition, graft materials as well as the follow up.
2:05.0	And a lot of series were done before the end of vascular and thus outdated.
2:09.0	However, more contemporary studies suggest that the incidence are ranging from one to six percent of our overall operations but approximately four percent in general.
2:17.0	And the real reason we care is because that these are very morbid complications and oftentimes to reconstruct a patient who has an aortic graft infection it requires an extensive open surgical repair.
2:27.0	And this can definitely be devastating patients who had a prior end of vascular repair and these patients have typically received an end of vascular repair for some reason such as their medical comorbidities.
2:37.0	This is not surprising that these patients that have an end of vascular aortic infection typically have a poor long term survival.
2:44.0	So Bobby, why don't you talk about the patients that get graft infections and who's typically at risk for those such cases.
2:50.0	Yeah, you bet Frank, thanks for that. So the majority of prosthetic aortic graft infections probably occur as a result of bacterial contamination at the time of original graft placement.
	...

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