Search

Objectives The presence of a fistula between the thoracic aorta and the esophagus is a rare and highly fatal condition. This study aimed to evaluate the outcomes of the surgical treatment of an aortoesophageal fistula (AEF). Methods We retrospectively reviewed patients with AEF who underwent surgery at our institution. Results Between 2007 and 2018, a total of 10 patients who underwent surgery for AEF. The mean age was 63 ± 12 years, and 6 patients were men. Four patients had primary AEFs and 6 patients had secondary AEFs (3 graft replacements and 3 thoracic endovascular aortic repairs). The timing of AEF since graft replacement or thoracic endovascular aortic repairs was 21.6 ± 27 days. We performed aortic replacement with a prosthetic graft (4 patients) or a homograft (5 patients) and extra-anatomical bypass due to a previous aortic graft infection (1 patient). As a treatment of the esophagus, we conducted primary repair in 7 of 10 patients. The median lengths of hospital and intensive care unit stay were 59 days (range, 9-225 days) and 6.3 days (range, 1-87 days), respectively. Seven patients achieved oral feeding after a median 10.3 postoperative days (range, 7-78 postoperative days). Two of the 10 patients died of sepsis at 9 and 74 days postoperatively. Conclusions The strategy for patients with AEF should be individualized. Our surgical strategy for AEF, which includes simultaneous aortic graft replacement and primary repair of esophagus in the same operative field, is feasible and promising.

Background: In thoracoabdominal aortic aneurysm repair, repairing the visceral and segmental arteries is challenging. Although there is a pre-hand-sewn and multi-branched graft based on the conventional image-based technique, it has shortcomings in precisely positioning and directing the visceral and segmental arteries. Methods: We introduce two new reconstruction techniques using patient-specific 3D-printed graft reconstruction guides: 1) model-based technique that presents the projected aortic graft, visualizing the main aortic body and its major branches and 2) guide-based technique in which the branching vessels in the visualization model are replaced by marking points identifiable by tactile sense. The graft reconstruction guides cover the segmentation, design, fabrication, post-processing, and clinical application of open surgical repair of thoracoabdominal aneurysm, and proved to be efficient for accurately reconstructing customized grafts. Findings: This study is demonstrated to the effectiveness and efficiency by evaluating conventional and new techniques with digital model. The accuracy, reproducibility, and satisfaction of the two new techniques were higher than that of the conventional technique, and the marking time requirement for graft reconstruction was reduced. Interpretation: The two new reconstruction techniques have the potential to improve outcome as they can solve anatomical hurdles for individual anatomical variation and focus on important procedures by reducing the level of fatigue of operating surgeons for lengthy and exhausting surgery. Funding Information: This study was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (HI18C2383). Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: The institutional review board for human investigations at Asan Medical Center approved this study with a waiver of informed consent from patients because of the use of retrospective clinical and imaging data. The data were de-identified, in accordance with the Health Insurance Portability and Accountability Act privacy rule.

The increasing number of abdominal aortic grafts due to abdominal aortic aneurysms has caused secondary aortoenteric fistulas to be seen more frequently as a cause of gastrointestinal bleeding. High index of suspicion plays a significant role in the diagnosis in patients having clinical symptoms ranging from fecal occult blood to massive gastrointestinal bleeding, accompanied by hemorrhagic shock. A 65-year-old male patient developed two secondary aortoenteric fistulas consecutively. The first one was aortic graft-jejunal and the second one was aortic graft-duodenal in a short period. Secondary aortoenteric fistula developed after aortobifemoral bypass. The patient underwent graft revision and jejunal repair. He was reoperated three months later due to the newly developed aortic graft-duodenal fistula. The duodenal defect was closed, and an extra-anatomic aortoiliac bypass was performed to avoid graft-related enteric fistula. The patient was discharged uneventfully and was free from any complication at nine months after surgery.

BACKGROUND: Aortic graft infection is one of the most serious complications of vascular reconstruction with the incidence of 1%. The clinical presentation can vary, which delays the diagnosis. CASE REPORTS: Infections in our patients affected iliac, inguinal region, and retroperitoneum, which are not relatively common sites of graft infection. We present clinical presentation, imaging procedures, and surgical treatment of three patients with unknown cause of late graft infection after 6, 7, and 9 years. CONCLUSION: In our presentations, the etiological factors of the infection are not known, but they suggest that events in the gastrointestinal tract may be related to them. Aggressive surgery should be taken into consideration as a first choice in the similar cases.

OBJECTIVESOur goal was to define characteristic patterns of 18F-fluorodeoxyglucose in non-infected patients with ascending aortic prosthetic grafts during the first year after surgery.METHODS18F-fluorodeoxyglucose positron emission tomography (PET)/computed tomography (CT) was performed at 3, 6 and 12 months postoperatively in 26 uninfected patients. Clinical, analytical and microbiological (blood culture) assessments were performed to confirm the absence of infection. FDG uptake intensity [measured through maximum standardized uptake values (SUVmax) and the target-to-background ratio] and distribution patterns were obtained. Models of generalized estimating equations were used to assess the evolution of the SUVmax over time. The results were compared to those in our endocarditis-over-ascending-aortic-graft series database. The receiver operating characteristic curves of the control group and the 12-month group were assessed.RESULTSAll patients showed increased uptake in all areas. The uptake pattern was heterogeneous in 47.4%, 43.5% and 42.3% at 3, 6 and 12 months. The means and standard deviations of the SUVmax in the graft were 4.80 (±0.99), 4.28 (±0.88) and 4.14 (±0.87) at 3, 6 and 12 months after surgery. A comparison of all values obtained in the 6th and 12th months compared to those from the 3rd month revealed a slow decrease that may persist after the first year. The cut-off value of SUVmax of 4.24 had an overall sensitivity of 84.6% and specificity of 57.7% for patients seen at 12 months.CONCLUSIONSNon-infected ascending aortic grafts showed no predominant uptake pattern; they also showed increased 18F-fluorodeoxyglucose activity that could persist beyond the first year. Caution is therefore recommended when interpreting PET/CT images obtained during the first year after surgery.

Aim: Primary outcome measures was to analyze the clinical consequence of patients who treated for infrarenal aorta synthetic graft infection ( SGI) with extra-anatomical bypass (axillobifemoral (AXF)) or in situ reconstruction (ISR). Secondary outcome measure was to show bacteriological analysis of abdominal aorta graft infection. Method: Analysis of medical records of 24 patients treated for SGI at Jordanian Royal Medical Services between June 2010 and Aug 2020 were retrospectively reviewed. For all patients, we recorded clinical features , morbidity and mortality , as well as bacteriology results, and antibiotic treatment . Result: We identified 24(3%) patients with SGI .The median follow up duration was 22 months range (8-84months). The median age was 52 years and 18 were males. An in situ prosthetic graft replacement, using rifampin-soaked polyester graft was performed in 10 patients(42%) and AXF in 14 patients((58%). The early hospital mortality rate was 4 (17 %.) owing to bowel ischemia 1 patient, 2 patients with septicemia and one patient with aortic stump blowout . There were no late procedure-related deaths during follow up period Primary patency and limb salvage rates at 3 years were 80 %(2 patients ) for ISR and 90%( 2 patients) for AXF. The incidence of graft reinfection was 10% (1 patient) for ISR and 8 %(2 patients) for AXF. Graft reinfection occurred in 3 patients (12.5%) was not associated with procedure-related death .Microbiology specimens obtained from the graft and the tissues were positive in 21 patients(88%). Poly microbial Gram-positive organisms were the most dominant bacteria found in 10 patients (42%). The mean length of hospital stay was 17 days . Conclusion: According to our study ISR and AXF is a safe and effective in treatment of aortic graft infection. Graft reinfection occurred in 12.5% of the patients. The graft patency and limb salvages rates were considered satisfactory.

Aortoiliac reconstruction using autologous deep femoral vein (neoaortic iliac system bypass [NAIS]) is a therapeutic option for management of prosthetic aortic graft infection. Complications after NAIS are complex and reported management strategies few. Endovascular procedures offer a minimally invasive alternative to high-risk, complex open surgery. We report a case of early aortic anastomotic failure after NAIS associated with a pseudoaneurysm and significant retroperitoneal hemorrhage, which was successfully treated by endovascular stent grafting.

Objectives Management of infected prosthetic aortic grafts in the ascending and or root is complex and multifaceted. We report our diagnostic pathway, management and outcomes, identifying successful strategies. Methods This was a retrospective, single center, observational study. Consecutive patients who underwent management of infected aortic grafts in the ascending and/or root at our institution between October 1998 and December 2019 were included. The main outcome measures were: discharge from hospital alive with at least 1 year survival, operative mortality and success of primary treatment strategy. Results Twenty‐six patients presented with infection of proximal aortic grafts and were managed through a number of strategies with an overall hospital‐survival of 81% and 1 year survival of 69%. Twenty of them ultimately underwent redo surgery with 25% operative mortality (within 24 h of surgery). Five patients underwent washout and irrigation of which two were successfully treated and cured with adjunctive antibiotics and two went on to have staged explant and definitive surgery. Interval between surgery and infection was 42.5 ± 35.8 months. All patients had at least one major criterion and three minor criterions with no diagnostic uncertainty. The commonest primary strategy was 3a (definitive surgery), (13/26, 50%). Conclusions Adopting a systematic and flexible patient specific approach to the diagnosis and management of patients with proximal aortic graft infections results in reasonable overall 1 year survival. In the majority of patients surgery is ultimately required in an attempt to achieve a curative treatment; however this comes with high operative mortality risk.

Stanford type A dissections usually require surgery because they are associated with high morbidity and mortality. However, there are situations where medical management becomes the definitive treatment. We report the successful medical management of a 16-month chronic type A aortic dissection in a 56-year-old male patient with a past surgical history of ascending aortic aneurysm repair. The dissection is unique because it is distal to the graft and does not extend into the main aortic branches. A review of a patient's surgical history and nonenhanced imaging studies is essential when a type A dissection is discovered. Ascending aortic grafts may preclude the most serious complications of type A dissections.

Introduction. Aortic graft infection (AGI) is a rare complication following AAA repair and is associated with high morbidity and mortality. Management is variable, and there are no evidence-based guidelines. The aim of this study was to systematically review and analyse management options for AGI. Methods. Data was collected between July and August 2018. A full HDAS search was conducted on the following databases: MEDLINE, EMBASE, CINAHL, and PUBMED. Meta-analysis was conducted using RevMan 5 software. Results. 1,365 patient outcomes were assessed (10 cohort studies and 12 comparative studies). The most common treatment was in situ replacement of the graft (ISR) followed by extra-anatomical replacement (EAR). Various grafts were used for ISR, such as fresh/cryopreserved allograft, venous graft, and prosthetic grafts. No graft material was shown to be superior. Axillobifemoral graft was the commonest type of EAR used. In the majority of cohort studies, ISR was the main treatment for AGI. There was no significant difference in the overall mortality rate (ISR n=70/176 vs. EAR n=47/126, OR 0.93 [95% CI 0.36-2.36], P=0.87). Graft occlusion rate was significantly lower in the ISR group vs. the EAR group (n=14/115 vs. n=29/60 OR 0.16 [95% CI 0.07-0.36], P<0.001). There was no significant difference in the amputation rate between the surgical treatments (ISR n=9/141 vs. EAR n=8/82, OR 0.75 [95% CI 0.07-8.39], P=0.82). Discussion. In situ replacement is the preferred method of treatment as it had lower rates of occlusion. Further strong evidence is required, such as a multicentre trial to establish a management pathway for the condition.

Dacron vascular prostheses have been widely used in vascular surgery since the mid-1970s. They have been proven to be the most durable and reliable conduits for arterial replacement in aortic and peripheral surgeries for decades. However, an extremely rare complication, namely late non-anastomotic graft rupture, due to intrinsic structural prosthetic disruption can occur, resulting in acute hemorrhage or false aneurysm formation. We report a case of this rare complication due to non-anastomotic rupture of a bifurcated knitted Dacron aortic vascular graft in a patient who had undergone an aorto-bi-iliac bypass 6 years ago. The patient was successfully treated in an emergency setting with endovascular therapy using an iliac limb of an abdominal aortic endoprosthesis.

Introduction Late occlusion of the entire stent graft after endovascular aortic repair (EVAR) is a rare condition which often requires open surgery. This is a case of endovascular rescue of chronic total occlusion of an aortic stent graft in a patient at high risk of open surgery and lysis. Report An 82 year old male was admitted with bilateral lower limb rest pain eight years after EVAR. Endovascular relining with a covered stent under local anaesthesia was planned. Antegrade recanalisation from brachial access was achieved, then VBX balloon expandable covered stents (W. L. Gore & Associates Inc. Flagstaff, AZ, USA) were deployed in a kissing configuration to reline the occluded stent graft, alongside a double renal chimney. The post-operative period was uneventful, and a six month CT angiogram confirmed the technical success with complete patency of the aorto-iliac segment and visceral arteries. Discussion Complete stent graft thrombosis after EVAR is typically managed by open conversion to aortobifemoral or axillobifemoral bypass graft, surgical thrombectomy or catheter directed thrombolysis, carrying a considerable mortality and morbidity rate. Endovascular relining with kissing covered balloon expandable stents with double renal chimneys is a less invasive option. By offering a unique combination of radial strength and flexibility, associated with a trackable delivery system and a high retention capability, the GORE VBX is the present authors’ preferred stent option for this procedure. The present case shows how endovascular recanalisation by antegrade and retrograde approaches may be an effective option, especially in a patient at high risk of open surgery and lysis., Highlights • Late occlusion of the entire stent graft after EVAR is a rare condition. • It is managed by conversion to aortobifemoral or axillobifemoral bypass. • It can also be managed with surgical thrombectomy or catheter directed thrombolysis. • Endovascular rescue is an option in patients at risk of open surgery and lysis.

The rectus femoris pedicled muscle flap is a widely used option for coverage of infected vascular grafts in groin reconstruction as well as in reconstruction of abdominal wall defects. Here we present the case of primary placement of a pedicled rectus femoris flap to provide well-vascularized tissue interposed between an aortic Dacron interposition graft and bowel. This previously undescribed use of the rectus femoris proves to be an indispensable method when the more common alternatives, such as omental and rectus abdominis flaps, are not available. Keywords: Rectus femoris flap, Aortic graft, Pedicled muscle flap

Although gastrointestinal hemorrhage from aorto-enteric fistulae (AEF) secondary to previous aortic grafts are well known, a primary aorto-enteric fistula (PAEF) without aortic aneurysm is an extremely rare event resulting in poor prognosis and outcome. PAEF is a rare cause of gastro-intestinal (GI) bleeding that radiologists should consider because often its presence is not easily guessed by clinical features. It is difficult to detect at CT examination therefore PAEF might be not diagnosed until a laparotomy. We report a case of a 74-year-old Italian male who presented to our Emergency Department (ED) with brightly red rectal bleeding that occurred from some hours and a pre-syncopal episode. There was no history of analgesic abuse, peptic ulceration, alcohol excess, and weight loss. Standard resuscitation was commenced with the hope that common sources of bleeding such as peptic ulcers or varices would eventually be discovered by endoscopy and treated definitely. An upper GI endoscopy showed brightly red blood in the stomach and in the first portions of duodenum, but no source of active bleeding was found. Diagnosis of PAEF was made by CT and after confirmed during surgical intervention. Both the duodenum and the aorta were successfully repaired by direct suture and synthetic graft replacement, respectively. Diagnosis of primary aortic duodenal fistula (ADF) has been very difficult in this case especially because our patient did not have abdominal aortic aneurism (AAA) history confirmed by CT examination. Radiologist should remember that upper GI bleeding could however be determined by primary ADF also if atherosclerotic damage is severe as in this case. A technically good and complete exam is mandatory to achieve this rare and complex diagnosis. Particularly, an ultra-tardive acquisition phase (5 min after contrast administration) could be helpful to suspect the presence of PADF: the appearance of contrast into the duodenal lumen is an evocative sign useful to increase clinical and radiological suspicious of ADF. Gl bleeding should be assumed to be caused from a PAEF unless another source can be identified without delay. A timely and accurate diagnosis of primary AEF may be challenging due to insidious episodes of GI bleeding, which are frequently under diagnosed until the occurrence of massive hemorrhage.

CASE RESOLUTION The patient was referred to the cath lab. The high left brachial artery access was tried using the dissection technique due to significant stenosis of the distal brachial artery as a consequence of an aortography performed during the patient’s childhood with the Sones technique. General anesthesia with selective orotracheal intubation was used. A 6-Fr Cobra-type guide catheter was advanced and entered the pseudoaneurysm. An early injection was used for its catheterization (video 1 and video 2 of the supplementary data) (neck: 8.4 mm; base: 2.9 x 1.5 cm). Three fiber coils (6 mm with 5 turns) were deployed in the base of the pouch (figure 1). Afterwards, a 5 x 4 mm Amplatzer ADO II device was positioned and delivered in the pseudoaneurysm neck. The persistence of the passage of contrast to the pouch was evident and it was decided to deliver another 6.5 mm fiber coil with 3 turns to finish the pseudoaneurysm neck sealing (figure 2, video 3 of the supplementary data). One month after the procedure, the patient had a new episode of hemoptysis. The coronary computed tomography angiography performed confirmed the patency of the pouch in its proximal portion, which is why the...

Aim to describe good outcomes in a case with Aortic graft infection (AGI) managed with Bovine patch and outline management of AGI. Method Literature review utilising keywords ‘’Aortic graft infection’’AND’’Bovine Patch’’ revealed initially 1350 articles, all studies in English were included, all duplicates were removed, screening was performed using the PRISMA flow. To correlate with the findings, we followed up a 72-year-old patient who presented with aortic graft infection followed by graft explantation and a fashioned Bovine graft insertion and followed up for 1 year for any re-infection in the clinics. Results Literature search resulted 73 articles discussing the role of Bovine Patch as a choice in prevention of Aortic graft re-infection. In our case, there was no clinical nor radiological evidence of Bovine patch re-infection for over a year. Literature review showed that AGI is a rare but serious complication with mortality up to 60%.The main management is IV antibiotics, followed by graft explantation and consideration of re-implantation of various types of grafts. The European society of vascular surgery (ESVS) guidelines recommend re-implantation with an aortic antibiotic soaked graft, yet re-infection rate is quoted at 20%. however, in our case Bovine graft was free from re-infection at 1 year follow up. Conclusions IV anitbioics and explantation remain the mainstay for treatment of aortic grafts infection, however, there is increasing evidence that Bovine grafts show excellent freedom from re-infection at follow up. Hence, this might be the conduit of choice when performing such surgeries; however, more evidence is needed.

A 51-year-old male patient post-Aortic valve replacement (#25 SJM) underwent redo supra-coronary ascending aorta replacement for ascending aortic aneurysm developed a peri-graft purulent collection 2 months later post surgery. He was successfully treated by debridement of infected tissues, antiseptic irrigation with povidone, and omental wrapping of graft. The patient was discharged after full course of antibiotics. Quick diagnosis with debridement, irrigation, and omental wrapping can be effective in the treatment of mediastinitis following graft replacement of the ascending aorta for preventing catastrophic complications

CASE PRESENTATION This is the case of a 23-year-old male with a past medical history of interrupted aortic arch after left subclavian artery emergency found in the 8th month of the his life. Back in 2004, the surgical correction attempted with a subclavian-aortic graft using a Dacron graft was uneventful. The procedure resulted in an improvement of the arterial blood pressure. The anomalies associated with the initial diagnosis were the anomalous origin of the patient’s right subclavian artery with an emergency following the interruption and a bicuspid aortic valve without stenosis or regurgitation. Additionally, in 2015, and due to a significant scoliosis of the spine, the patient underwent surgery with placement of screws and rods. Back in January 2018, the patient became sick due to a massive hemoptysis that required the use of hemoderivatives. From the start the patient had a total of 17 episodes, the last one of approximately 1 liter with a reduction of hemoglobin levels down to 7 g/dL. The patient was admitted to our center in October 2019 with a coronary computed tomography angiography performed back in April 2019 (figure 1) and in a period of 5 days. The clinical and CT scan assessment revealed the presence of a...

Introduction and Importance Acute limb ischemia after infrarenal aortic repair is a rare complication, which in mainly described to appear in a short time after surgery. The aim of this paper is to describe a case of a 66-year-old woman who presented at out attention with acute right limb ischemia, one year later an aortic repair for acute abdominal aortic aneurysm rupture. In the best of our knowledge there are no cases of sudden graft occlusion after such long time, described in literature. Case presentation Patient presented with sudden pain and pallor in the right lower limb and subsequently same symptoms to the left lower limb. One year before she underwent an emergency repair for abdominal aortic aneurysm rupture with an aortobiliac graft. Computed Tomography Angiography (CTA) scan showed a complete occlusion of the infrarenal aorta, including aortoiliac graft, to the common bilateral iliac arteries. On the right side was also found a complete occlusion of the popliteal artery. Emergent embolectomy of the right popliteal artery via the femoral artery was performed. Clinical discussion CTA scan performed on third post-operative day showed the patency of infrarenal aorta and aortic portion of the grafts in presence of floating thrombus, right iliac branch patency and chronic occlusion of left iliac branch. A kinking of both graft iliac branches was evident after this CTA scan. CTA scan at one month demonstrated resolution of the thrombosis of the infrarenal aorta, complete patency of aortic portion of the graft and right iliac branch and chronic obstruction of the left common iliac artery. Conclusion Acute limb ischemia caused by sudden graft occlusion one year later an aortic repair for acute abdominal aortic aneurysm rupture is a very rare event. Graft limbs kinking could explain acute thrombosis of the graft., Highlights • Acute limb ischemia caused by sudden graft occlusion is a very rare event. • Thromboembolism is the most frequent cause for early acute limb ischemia after AAA. • Graft limbs kinking could explain acute thrombosis of the graft.

Aortic prosthesis infection is associated with significant morbidity and mortality rates. The introduction of the neo-aortoiliac system (NAIS) technique offers a new perspective, as a venous conduit is considered an optimal graft in aortic prosthesis infection because it is autogenous, durable, inexpensive and has low infection rates. Occasionally, the anatomical characteristics of available autologous venous conduits may limit the applicability of this technique. Herein, we present two cases in which a variant NAIS technique was used to confront an aortic graft infection. To expand the usefulness of the NAIS technique and avoid the use of prosthetic material in a potentially contaminated area as much as possible, we combined an autologous femoral vein with a short segment of a silver-coated Dacron graft. The combination of a silver-impregnated graft and the NAIS is a feasible bailout technique should the NAIS vein appears inadequate upon exploration.

Summary:. Replacing an infected prosthetic thoracic aorta graft carries a high re-infection risk. We previously reported two clinical cases successfully treated with a new muscular wrapping technique: latissimus dorsi (LD) muscle flap with a distally based serratus anterior (SA) extension; however, a cadaveric study to prove the regular existence of the distal attachment area was lacking. We tried to establish an appropriate way of elevating the combined muscle flap safely. All of the cadavers were preserved using the Thiel embalming technique to retain flexibility. We checked for the existence of the distal attachment area between the LD and SA. Combined muscle flaps were elevated proximally while identifying the thoracodorsal artery, including the LD and SA branches. After the SA branch was ligated and cut, the SA muscle was manually peeled from the LD muscle with only the distal tight attachment area remaining. Contrast-enhanced computed tomography was performed using a multislice computed tomography system. Six human cadavers (three men, three women: 91 years old, on average) were examined. All six LD and SA combined muscle flaps showed a distal tight attachment area at the level from the seventh rib to the ninth rib. The tip of the SA muscle easily reached the sternum. Contrast-enhanced computed tomography failed to reconfirm the distal vascular flow from the LD to the reverse SA muscle, which we had visualized in a clinical case. We demonstrated the anatomical reliability of the new Y-shaped muscular flaps, which are suitable for preventing re-infection of aortic graft replacement.

Background Endovascular aneurysm repair (EVAR) has become the treatment modality of choice in patients with abdominal aortic aneurysms. This has resulted in endograft utilization within instructions for use (IFU) and in cases with proximal neck anatomy outside of IFU. Purpose To identify whether graft selection influences outcomes following EVAR outside of IFU. Methodology A retrospective analysis was conducted from previously published data for 636 patients, collated from the Endurant Stent Graft Natural Selection Global Post-Market Registry (ENGAGE) and the Global Registry for Endovascular Aortic Treatment (GREAT). Patients were recruited into the ENGAGE registry between 2009 and 2011 and into the GREAT registry between August 2010 and October 2016. In ENGAGE, they received the Medtronic Endurant stent graft (Medtronic Vascular Inc, Dublin, Ireland) for infrarenal AAA repair while patients analyzed in GREAT received the Gore Excluder stent-graft (W. L. Gore & Associates, Flagstaff, Arizona). Analyses were performed to evaluate all-cause mortality, aneurysm-related mortality, endoleak occurrence, and surgical reintervention rates between the two cohorts. Results Of the 636 patients, 225 were from ENGAGE (mean age 73 years) and 411 were from GREAT (mean age 75 years). 17.8% were treated outside of IFU in the ENGAGE registry, while 12.4% were treated outside IFU in the GREAT cohort. Five-year freedom from all-cause mortality was similar in both cohorts (65.6% vs. 63.8%). The rate of type IA endoleak development was lower in the Excluder cohort, although this may have been impacted by the fact that only endoleaks that underwent reintervention were recorded within GREAT analysis (Endurant 10.6% vs. Excluder 7.0%). The reintervention rate was 16% at five years following the Endurant aortic graft while it was 13.3% at five years with the Excluder. Conclusion Treatment outside of IFU, be it with a suprarenal or an infrarenal fixation device, is associated with worse outcomes. This analysis reinforces the importance of the consideration of either fenestrated or open repair in those aneurysms that fail to satisfy IFU while endovascular repair in such a setting should be reserved as a last resort strategy.

Background Postoperative thoracic aortic graft infection (TAGI) is a serious and potentially fatal complication. The classical approach is to replace the infected graft. However, this approach has a high mortality rate. Alternatively, treatment of TAGI without graft replacement can be performed METHOD: Herein, we present a 72-year-old case with mediastinitis and graft infection after type A aortic dissection operation and successful treatment using omental flap coverage following vacuum-assisted wound closure therapy without graft replacement. Conclusion The patient had an uneventful postoperative course and remains infection-free to date.

In this case, a 22-year-old man sustained multiple gunshot wounds to the abdomen, which required in extremis surgical exploration with damage control laparotomy and hemostatic resuscitation in the surgical intensive care unit. Diagnostic angiography was negative and an inferior vena cava (IVC) injury was suspected. He was returned to the operating room, where the infrarenal IVC was accessed by direct puncture and venography demonstrated active extravasation of the suprarenal vena cava. The injury was successfully sealed with two overlapping endovascular aortic grafts, with care taken to preserve flow from the renal and hepatic veins. He made a full recovery and was discharged home on hospital day 20. Outpatient follow-up computed tomography at 2 months revealed a patent stent with preserved branches. Stent graft repair of penetrating IVC injury can be lifesaving and warrants further investigation.

An 82-year-old man with a history of endovascular repair for ruptured abdominal aortic aneurysm 6 years ago presented with a type II endoleak and enlarging sac. He had successful transabdominal direct sac puncture embolization but developed fever 2 days postoperatively. Contrast-enhanced computed tomography showed a rim-enhancing collection, and sac aspiration was positive for enteric organisms, confirming endograft infection. The patient underwent graft explantation and neoaortic reconstruction using superficial femoral veins. Three months postoperatively, computed tomography showed complete resolution of fluid collection and no signs of graft infection. This report illustrates direct puncture embolization complicated by endograft infection from enteric bacteria. Keywords: Abdominal aortic aneurysm, Endovascular aneurysm repair, Graft infection, Endoleak embolization, Aortic reconstruction

Which graft material is the optimal graft material for the treatment of aortic graft infections is still a matter of controversy. We used a branched xenopericardial roll graft to replace an infected aortic arch graft as a “rescue” operation. The patient is alive and well 37 months postoperatively without recurrence of the infection and any surgical complication. This procedure may have the possibility to serve as an option for the treatment of aortic arch graft infection.

BackgroundMarfan syndrome (MFS) is a connective tissue disorder characterised by complex aortic pathology and a high prevalence of obstructive sleep apnoea (OSA). OSA produces intrathoracic transmural stresses that may accelerate aortic injury. The current study was designed to examine the associations between OSA risk and markers of aortic enlargement in MFS.MethodConsecutive patients with MFS were recruited at Johns Hopkins if they completed a STOP-BANG survey. Composite survey scores were categorised into those with low OSA risk (STOP-BANG ResultsOf the 89 participants studied, 28% had a high OSA risk and 32% had aortic grafts. Persons with high OSA risk had greater aortic root diameter (mm) (ß=4.13, SE=1.81, p=0.027) and aortic root dilatation (ß=2.80, SE=1.34, p=0.046) compared with those with low OSA risk . In addition, the odds of prior aortic root replacement was three times greater in those with high OSA risk compared with those with low OSA risk.ConclusionIn MFS, high OSA risk is associated with aortic enlargement and a threefold increased risk of having had prior aortic root replacement. These findings invite further exploration of the relationship between OSA and aortic disease in MFS, and studies to clarify whether targeted interventions for OSA might mitigate aortic disease progression in MFS.Registration numberIRB00157483.

Staphylococcus lugdunensis has been reported to cause a wide variety of serious infections to include infective endocarditis, peritonitis and osteomyelitis. This report describes our patient who developed aorto bifemoral graft infection with Staphylococcus lugdunensis not previously described in the literature. Bangladesh Crit Care J September 2021; 9 (2): 116-117