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Aortobifemoral Graft Infection: Is Unilateral Limb Excision Definitive?
Jeffrey D. Crawford, MD, Amir F. Azarbal, MD, Timothy K. Liem, MD, Gregory J. Landry, MD, Gregory L. Moneta, MD, Erica L. Mitchell, MD.
Oregon Health and Sciences University, Portland, OR, USA.
OBJECTIVES
Aortobifemoral graft (ABFG) infections presenting with single limb involvement can be managed with unilateral limb excision or complete graft removal. This study aims to identify factors predictive of subsequent contralateral limb infection in patients initially undergoing unilateral limb excision.
METHODS
A retrospective review of patients treated for infected ABFGs from 2001-July 2014 was performed. Endovascular and aortic tube graft infections were excluded. Primary outcomes were freedom from contralateral graft limb excision, overall survival and factors potentially predictive of subsequent contralateral limb infection.
RESULTS
Fifteen patients underwent unilateral graft limb excision with retroperitoneal exploration of the affected ABFG limb and revascularization for unilateral graft limb infection. Original indication for placement of the ABFG was aortoiliac occlusive disease in 11 patients and aneurysm in 4. All patients had no clinical or radiographic evidence for contralateral limb infection at initial presentation. Seven patients, all of whom underwent initial operation for aortoiliac occlusive disease developed contralateral limb infection at a median follow up of 23.2 months. The remaining 8 patients had no evidence of contralateral limb infection at median follow up of 38.8 months. Patient demographics were similar between the two groups. Five of the seven patients who developed contralateral limb infection had imaging evidence of ipsilateral graft infection above the inguinal ligament at the time of initial graft infection. Operative exploration during unilateral excision in this group revealed a well-incorporated graft without extension to the bifurcation. There was no dominant organism cultured in either group and duration of targeted antibiotic therapy was similar in both groups (≥ 6 weeks). For the series, there were no amputations and overall mortality was 40% with median follow-up of 44.7 months.
CONCLUSIONS
Unilateral infection of an ABFG can be managed with single limb excision, however, 50% of patients will return with contralateral limb infection at a median of two years. Clinical assessment of graft incorporation lacks specificity and does not indicate freedom from contralateral limb infection. Factors predicting contralateral involvement include initial operation for aortoiliac occlusive disease and initial imaging or operative findings suspicious for infection above the inguinal ligament of the unilateral limb.
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