Clinical Challenges in Vascular Surgery: Aortic Graft Infections

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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