Outcomes of Simultaneous v Staged Extra-Anatomic Bypass Grafting with Aortic Ligation to Address Aortic Infections
Paul Armstrong, DO, Jeffrey B. Edwards, MD, Danielle T. Fontenot, MD, Martin R. Back, MD, Murray L. Shames, MD.
University of South Florida, Tampa, FL, USA.
OBJECTIVES: This review compares the perioperative and one-year outcomes between simultaneous and staged axillobifemoral (AxBF) bypass for the treatment of primary and secondary aortic infection. METHODS: A retrospective review was conducted of a single-center vascular registry. All patients who underwent AxBF for the treatment of aortic infection between 2001 and 2016 were included. Standard demographic data were collected in addition to perioperative parameters and post-operative outcome measures up to one year. Primary outcome was freedom from mortality. Secondary outcomes included need for repeat procedures, rates of kidney injury and major adverse cardiopulmonary events, ICU length of stay, and transfusion requirements. RESULTS: We identified 107 aortic infections treated with simultaneous or staged AxBF reconstructions with aortic debridement and ligation. Indications for treatment were 52 aortoenteric erosions (AEE), 4 mycotic aneurysms, and 51 bacterial graft infections (16 endovascular, 26 Dacron, and 9 PTFE). Seventeen (16%) patients received urgent simultaneous graft explants and AxBF due to bleeding associated with AEE. Thirty-nine (36%) patients underwent elective simultaneous AxBF and explant. The remaining 51 (48%) had a staged AxBF followed by graft explant within 48 hrs of the AxBF construction. Total operative times, estimated blood loss, number secondary procedures, limb salvage rates, incidence acute kidney injury, chronic renal failure requiring hemodialysis, and cardiopulmonary morbidity were similar between simultaneous and staged procedures. ICU length of stay (LOS) and transfusion requirements were higher for the staged group. Overall mortality at 1 year was 13%, with 9 early (< 30d) deaths (4 simultaneous, 5 staged) due to disseminated intravascular coagulation (n=1) and multi-organ dysfunction syndrome (n=8) and 5 late deaths due to cardiac (n=4) or unknown (n=1) etiology. All AxBF were patent at 30 days. Ten grafts (4 simultaneous, 6 staged) required late (>30d) secondary intervention by the end of one year. Five grafts required thrombectomy and revision for thrombosis, 1 thrombosed graft was converted to a thoraco-bifemoral bypass, 2 graft revisions were performed for abnormalities noted on surveillance imaging, and 2 grafts were revised for femoral limb infections. CONCLUSIONS: Major clinical perioperative and early outcomes are similar for patients receiving explant of an infected aortic graft with simultaneous or staged AxBF. Experienced centers for aortic care should continue to utilize extra-anatomic AxBF bypass in select cases of aortic infection.
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