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Autogenous Vein Reconstruction May Not Protect Against Re-infection of Infrarenal Aortic Grafts
Kristofer M. Charlton-Ouw, MD1, Harleen K. Sandhu, MD1, Guanmengqian Huang, MD2, Samuel S. Leake, BS1, Charles C. Miller, III, PhD3, Ali Azizzadeh, MD1, Sheila M. Coogan, MD1, Anthony L. Estrera, MD1, Safi J. Safi, MD1.
1University of Texas Medical School at Houston, Houston, TX, USA, 2Shanghai Jiaotong University, Shanghai, China, 3Texas Tech University Health Sciences Center, El Paso, TX, USA.
Objectives: Prosthetic graft infection is a devastating complication of infrarenal aortic reconstruction. Although isolated reports of medical management exist, definitive treatment requires excision of infected grafts. Some advocate autogenous femoropopliteal vein reconstruction as being more resistant to re-infection. However, harvesting the femoropopliteal veins adds considerable morbidity and operative time compared to other reconstruction methods. We reviewed our cases of infrarenal aortic graft infection to determine morbidity and risk of re-infection.
Methods: We retrospectively reviewed cases referred to our institution with infrarenal aortic graft infection from 1999-2011. Cases requiring graft excision were included for analysis. Reconstruction included extra-anatomic and in situ autogenous femoropopliteal vein, cryopreserved cadaveric homograft, polyester (Dacron), and polytetrafluoroethene (PTFE). Patient co-morbidities, surgical outcomes, and known re-infection rates were assessed. Logistic regression analysis was performed.
Results: 23 patients required excisional treatment for infrarenal graft infection (27 graft excisions and 26 reconstructions). Median age was 63 (range 46-86) with 8 females. One patient underwent graft excision without revascularization. In situ reconstructions included 10 autogenous vein, 5 Dacron, 4 homograft, 1 homograft/autogenous, and 1 homograft/Dacron composite. Five patients had extra-anatomic axillofemoral reconstructions. Staphylococcus spp. were most commonly cultured (52%, 12/23 patients). Patient co-morbidities, including diabetes, renal insufficiency, coronary disease, pulmonary disease, original operative indication (aneurysm vs. occlusive disease), and tobacco use did not correlate with in-hospital morbidity or mortality on logistic regression analysis (p=ns). In-hospital mortality occurred in 4 of 26 reconstructions (15.4%, none with autogenous vein). All in-hospital deaths occurred in patients with aortoenteric fistulas. The 5-year all-cause mortality was 65.2%. Known re-infection occurred in 4 patients over the follow-up period (median 9 months, range 1 month to 11 years), including 2 autogenous vein reconstructions. Both had gram-negative infections (M. morganii and E. coli). 4 patients eventually required lower extremity amputation, including 2 with autogenous vein reconstructions, for a limb salvage rate of 78.3%. 1-year amputation-free survival was 33% for autogenous and 55% for non-autogenous vein in situ reconstructions.
Conclusions: Excision of infected prosthetic infrarenal aortic grafts can be done with acceptable in-hospital morbidity and mortality rates. Revascularization with in situ autogenous femoropopliteal vein may not protect against re-infection or limb loss, especially in the setting of gram-negative enteric bacteria. Long-term survival rates are dismal and may be due to late unrecognized re-infection.
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