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Background Though infrequent, allograft nephrectomies are performed for early and late graft loss. The study aims to analyze the histopathologic characteristics of allograft nephrectomy specimens. Materials and Methods We conducted an observational study of 103 cases of allograft nephrectomies from 21 centers from 2013 to 2023. All the pathology slides, including hematoxylin and eosin-stained sections, masson trichrome, jones methenamine silver, PAS, GMS, AFB, and immunohistochemistry (C4d, SV40) were reviewed. Pathologic findings were analyzed based on the transplant to nephrectomy interval (0–3 months, > 3 months) and type of donor (deceased, live donor). Results Of the total 103 cases, 77 were male. The mean age at the time of nephrectomy was 36.4 (range 5–64) years. The allografts were obtained from deceased (57) donors and live related (46) donors. Graft tenderness, oliguria/anuria, and fever were common clinical presentations. The majority (71.8%) of the nephrectomies were performed within the first 3 months of renal transplant. Renal vessel thrombosis (32.03%) was the most common pathologic finding. Infections were more common in the first 3 months after the transplant. Fungal infection had a significant association with deceased donor transplantation (p = 0.029). Conclusion Histopathological study of allograft nephrectomy specimens aids understanding of graft loss causes. The study also provides opportunities to prevent complications and implement measures to prolong graft survival in a subsequent transplant. [ABSTRACT FROM AUTHOR]

Background/Objectives: Vascular graft infections (VGIs) represent a life-threatening complication, occurring in 0.2–6% of patients following aortic prosthetic placements. Historically, the primary focus for reducing VGIs has been on prevention. Currently, antimicrobial grafts are not available on the market. This study aimed to evaluate the efficacy of combining two antibiotics, fosfomycin and oritavancin, impregnated into the commercially available GelweaveTM vascular graft as a prophylactic alternative against the most commonly implicated bacteria responsible for VGI. Methods: The antimicrobial activity of fosfomycin and oritavancin was assessed using the broth microdilution method, and a synergistic effect was demonstrated using the checkerboard assay against Staphylococcus epidermidis, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant Enterococcus faecium. The antibiotics were impregnated into the commercial vascular graft through immersion, and the antimicrobial efficacy of the fosfomycin/oritavancin-impregnated graft was assessed over a period of 7 days. Results: Eradication of all microorganisms tested was achieved using impregnation solutions with concentrations of 40 mg/mL of fosfomycin and 256 µg/mL of oritavancin. Conclusions: Impregnation with the combination of fosfomycin/oritavancin proved to be a promising approach to prevent VGIs. Vascular grafts with impregnated antibiotics are not yet available on the market, and this work represents an important step toward the development of a new class of antimicrobial vascular grafts. [ABSTRACT FROM AUTHOR]

Background Although the true prevalence and incidence are not clearly known, mycotic pulmonary artery aneurysm is a potentially devastating condition that leads to high mortality, over 60% if untreated. Among them, mycotic pulmonary artery pseudoaneurysm, which occurs in relatively central areas, has rarely been reported. We report an extremely rare case of a late complication with a mycotic pulmonary artery pseudoaneurysm, presumably due to infective endocarditis, in a 68-year-old woman 4 months after total arch replacement. Case presentation A 68-year-old woman was referred to our department for 2 weeks with fever of unknown origin. She had a history of emergency total arch replacement for an acute type A aortic dissection 4 months earlier and chronic rheumatoid arthritis on monthly subcutaneous tocilizumab treatment for several years. Blood culture was positive for Enterococcus faecalis. Transthoracic and transesophageal echocardiography revealed a left ventricular ejection fraction of 58%, severe mitral regurgitation with a 15-mm diameter vegetation on the anterior mitral leafet, and severe aortic insufciency with string-like structures. Contrast computed tomography showed a focal saccular outpouching from the right pulmonary artery. On 18F-fuorodeoxyglucose (FDG) positron emission tomography, focal uptake of FDGs was observed along the same lesion of the pulmonary artery and ascending-arch graft. The patient eventually recovered after the surgical intervention of mitral and aortic valve replacement, re-total arch replacement, pulmonary artery repair, application of omental fap, and antibiotics without any evidence of re-infection after 1 year. Conclusions We report a successful surgical repair of mycotic pulmonary artery pseudoaneurysm 4 months after total arch replacement for acute type A aortic dissection. This report describes an efective treatment for an extremely rare postoperative condition. [ABSTRACT FROM AUTHOR]

Aortic graft infection is an uncommon but highly fatal complication. Correct diagnosis and timely treatment are somewhat challenging. This study presents a case report of successful recognition and treatment of this complication.

Aim: To analyze the clinical outcome of first 100 consecutive cases of therapeutic penetrating keratoplasty (TPK) done at a tertiary eye care centre in Eastern India. Materials and Methods: A retrospective analytical observational study of first 100 consecutive patients of TPK was done at RIO, IGIMS, Patna, Bihar for nonhealing keratitis with or without perforation with a minimum 1 year follow up examination. Patients with vitreous exudates were excluded from the study. Results: Organisms were isolated in 60% of cases of which 65% were fungi (Aspergillus), 20% were bacteria, (Staphylococcus aureus) and 15% had mixed infection. 17 cases required lens removal during surgery. Repeat graft infection was noticed in 23 cases of which 9 had fungi, 2 had bacterial isolate and rest was inconclusive preoperatively. A repeat TPK was performed in 7 patients out of the reinfected cases. Anatomical restoration could be achieved in 96% of cases. Graft clarity allowing clear view of anterior chamber could be seen in 26 cases. 4 cases of graft infection with posterior segment involvement finally required evisceration. 47 out of 100 TPK cases had raised intraocular pressure (IOP) of which 10 underwent glaucoma surgery for uncontrolled IOP despite medications. Conclusion: TPK is a challenging surgery still having definite role in management of nonresponding progressive keratitis. Maintaining graft clarity postoperatively is a difficult task in these cases therefore success should be measured in terms of infection eradication and anatomical restoration.

Background and Objectives: This study was conducted to investigate whether Pseudomonas aeruginosa (PA) infections of arteriovenous grafts (AVGs) recur more frequently than other bacterial infections following treatment with revision. Materials and Methods: Operative procedures, including total excision, subtotal excision, and revision, were performed on 60 patients to treat 65 AVG infections. Final outcomes were classified as no infection recurrence, infection recurrence, and death without prior recurrence. In the competing risk setting, the cumulative incidence was estimated using the cumulative incidence function and Gray's test, and the associations between outcomes and different variables were estimated using a subdistribution hazard (SDH) model. Results: Comparing AVG infections with and without recurrence, PA infection was not associated with a higher risk of infection recurrence (p = 0.13); however, the first operative procedure type was associated with infection recurrence (p = 0.04). AVGs with PA infection were associated with a higher total number of surgical interventions (p < 0.05) than AVGs without PA infection. Regarding the cumulative incidences of outcomes, for AVGs treated with subtotal excision or revision, the cumulative incidence of recurrent infection was 3.3-fold higher for those with PA infection than without one year after the first surgery. However, when AVGs were treated with revision alone, the cumulative incidence was 4.1-fold. After excluding AVGs treated with total excision, the SDH model was applied, obtaining a hazard ratio for infection recurrence of 16.05 (p = 0.02) for AVGs with PA infection compared with AVGs without PA infection. No other variables were significantly associated with infection recurrence. Conclusions: For subtotal resection and revision, AVGs infected with PA had a higher recurrence rate than those infected with other species. However, revision surgery may aggravate the recurrence rate. [ABSTRACT FROM AUTHOR]

Abstract Background An aortic graft implantation is an effective therapeutic method for various aortic diseases. However, it is known that sometimes these implanted grafts can be the foci of infections. Here we report a rare case of graft infection that presented multiple embolisms of aortic branches and peripheral organs. Case presentation A 63-year-old Japanese woman with a history of aortic graft implantation presented with occlusions of large arteries in different loci and time points, with elevation of non-specific inflammatory markers. Thoracic contrast-computed tomography (CT) captured vegetation in the descending aortic graft and the [18F]fluorodeoxyglucose positron emission tomography/computed tomography ([18F]FDG PET/CT) showed accumulation of FDG in the same site, suggesting a graft infection. Despite all these suspicious findings, repeated blood culture examinations never detected any microorganisms. A diagnosis of Aspergillus graft infection was made based on an elevated serum β-D glucan (βDG) and a positive Aspergillus galactomannan (GM) antigen test. The patient subsequently had surgery with replacement of the descending aortic graft and anti-fungal drugs were instituted with significant improvement noted. Conclusion In the present case, the patient’s specific feature in the anatomical vascular construction, past operation, and basal fundamental diseases collaboratively contributed to the pathogenesis of the present infection. It is important to recognize the risk of graft infection and conduct imaging studies when indicative symptoms emerge. The negativity in blood culture studies often makes detection of pathogenic microbes extremely difficult. This case suggests that non-cultural tests such as bDG and GM can be useful for diagnosis and starting appropriate anti-fungal drugs in the early stages.

Prosthetic infection is the most common complication after aortic replacement with a synthetic vascular prosthesis or a valved conduit (VC); in this case, aortic valve (AV) rupture occurs in 0.1-1.3% of patients. The cause of valve rupture is not only infective endocarditis; ascending aortic aneurysm and obvious calcification of the native AV are also known risk factors. The paper describes a clinical case of a 49-year-old patient examined and treated in Petrovsky Russian Scientific Center of Surgery. Eighteen years after primary surgical intervention for aortic stenosis, AV reprosthesis and ascending aorta VC replacement were performed according to the Bentall - De Bono procedure modified by Kouchoukos. In 2021, computed tomographic aortography has revealed that in the presence of infective endocarditis, there is aortic prosthetic rupture to form a paraprosthetic fistula and a pseudoaneurysm cavity. The results of instrumental studies are comparable with intraoperative data. The clinical case is of interest due to the rare occurrence of complications and to the significant role of multislice computed tomography during examination and postoperative monitoring.

INTRODUCTION: Vascular graft infections are a rare and severe complication of open aortic surgery. As such, strategies to improve diagnosis and management are paramount. Nevertheless, there is little evidence regarding the factors associated with a higher susceptibility of infection. Moreover, there is little consensus on the best diagnostic workup and most adequate approaches to control and mitigate this surgical complication. We aim to summarize the latest evidence on aortic graft infection through a narrative review. METHODS: We conducted a literature search in a medical database "PubMed" and included studies on vascular graft infection and aortic repair. RESULTS: So far, patient-related comorbidities (such as diabetes, smoking, advanced age and chronic kidney disease), as well as procedure-related factors (location and type of graft, postoperative hyperglycemia, bacteremia, emergency setting), have been reported. Unlike extracavitary infections, aortic graft infections may present with subtle or no clinical manifestations. Aortoenteric fistulas are the exception to the rule, carrying a significantly higher mortality rate. All patients should be thoroughly tested with full blood counts, blood cultures and extensive imaging studies. Adequate antibiotic therapy is one of the pillars of treatment and should not be delayed. The selection of the antimicrobial regimen should be personalized and made in a multidisciplinary team. Surgical strategies are of paramount importance in controlling infection. These can be divided into graft- sparing techniques and graft explantation. The choice of the appropriate approach depends on the surgeon’s experience, the extent of disease and the patient’s general status and comorbidities. CONCLUSION: Aortic graft infections are a rare and severe complication of vascular surgery. A swift diagnosis and management are paramount. Despite significant efforts on how to treat the infection with more adequate antibiotic and surgical therapies, effective preventive measures and a clear definition of predisposing factors remain the main areas for future studies.

INTRODUCTION: Secondary Aortoesophageal fistula (AEF) is a rare but serious complication following thoracic endovascular aneurysm repair (TEVAR), which may lead to fatal outcomes. CASE REPORT: We present the case of a 62-year-old patient developing a secondary AEF one-month after TEVAR. The patient was managed in a staged approach: first, an oesophagus defunctionalisation by cervical oesophagus stapling, followed by drainage gastrostomy and creation of a feeding jejunostomy. Two-weeks later, the patient underwent stent graft explantation, extensive debridement, in situ aortic reconstruction with interposition of a silver and Triclosan impregnated Dacron graft, esophagectomy, eosophagogastrostomy and intercostal muscle flap plasty. After 4 years of follow-up, the patient remains clinically well and free from recurrence. CONCLUSION: The diagnosis of AEF requires a high index of suspicion. A prompt and aggressive multidisciplinary approach is necessary to obtain long-term survival and freedom from recurrence.

Introduction: Graft infections are severe complications. Surgical resection of infected aortic stent grafts is associated with high mortality and morbidity. Therefore, alternatives or adjuncts to antibiotic treatment and extensive surgery are urgently needed. Report: A 67 year old woman was admitted with a methicillin sensitive Staphylococcus aureus infected stent graft in the thoracic aorta. Local infection was confirmed by PET-CT imaging. Surgical resection of the stent graft was not feasible because of comorbidities. Therefore, a three step approach for local bacteriophage treatment was performed as a last resort treatment. Firstly, the para-aortic tissue was debrided via left thoracotomy, a bacteriophage suspension was applied on the outer surface of the aorta, and a vacuum irrigation system was installed. After repeated alternating instillation of the bacteriophage suspension for three days, as a second step, the vacuum sponges were removed and a bacteriophage containing gel was applied locally on the outer surface of the aorta. In the third step, the bacteriophage containing gel was applied to a thoracic stent graft, which in turn was placed endovascularly into the infected stent. Discussion: After 28 days, the patient was discharged from hospital with normalised infection parameters. PET-CT imaging at three and 12 months post-intervention did not show signs of infection in or around the thoracic aorta. This Case demonstrates successful treatment of an infected endovascular stent graft by application of bacteriophages both to extravascular and, as a novel approach, endovascular sites using a bacteriophage coated stent graft.

INTRODUCTION: Endovascular aneurysm repair (EVAR) offers significant advantages on aneurysm treatment. However, the management of EVAR complications or failure often results in complex surgical approaches, sometimes requiring graft explantation which remains a major challenge and one associated with a high morbidity and mortality. The purpose of this study is to review our contemporary institutional experience with EVAR explantation. METHODS: An institutional administrative database was reviewed to identify patients who were subject of graft explantation following standard infra-renal EVAR between 2011 and 2021. Follow-up was extracted from patient charts. The primary endpoint was perioperative mortality (30-days or in-hospital). Demographics, indications for explantation and procedure details were evaluated. RESULTS: Over a 10-year period, between 2011 and 2021, there were 617 standard primary EVAR procedures performed in our institution for infrarenal aortic aneurysms. During this period, we identified 13 patients submitted to EVAR explantation, two of which were referrals from other vascular centers. All patients were male and mean age at explantation was 71 years (range 47-81). The primary EVAR procedure took place 29 months (range 0-72) before explantation. The primary indication for EVAR was ruptured aortic aneurysm in seven patients. The majority of explantation operations were emergent (6/13, three due to unstable aorto-enteric fistula (AEF), three due to rupture) or urgent (4/13, two stable AEF, two graft infections). In 3 cases, explantation was elective (two type Ia endoleaks and one type II endoleak with sac expansion). None of the patients had been submitted to a previous attempt at endovascular salvage. All patients were submitted to transperitoneal approaches, and all required initial supracoeliac or suprarenal aortic clamping. After explantation, in situ reconstruction was performed in eight patients, six of which with complete EVAR explantation and two with partial EVAR explantation. Two in situ reconstructions were made using superficial femoral veins, and the remaining used prosthetic grafts. Aortic ligation and extra-anatomic bypass were performed in five cases, The 30-day mortality was 54% (seven patients) with 33% of mortality for elective repair, 50% mortality for urgent repair, and 67% mortality for emergent repair. Mean hospital stay after surgery was 48 days for survivors. Mean survival after discharge was 10 months. CONCLUSION: EVAR explantation is still a relatively rare and particularly complex procedure. When the reason for explantation is graft infection and AEF, and when performed in an emergent context, it is a particularly morbid procedure with a dismal prognosis. As the number of endovascular aneurysm repairs increase, our global experience will become increasingly important in bettering our surgical and clinical outcomes.

Background and Objectives: This study was conducted to investigate whether Pseudomonas aeruginosa (PA) infections of arteriovenous grafts (AVGs) recur more frequently than other bacterial infections following treatment with revision. Materials and Methods: Operative procedures, including total excision, subtotal excision, and revision, were performed on 60 patients to treat 65 AVG infections. Final outcomes were classified as no infection recurrence, infection recurrence, and death without prior recurrence. In the competing risk setting, the cumulative incidence was estimated using the cumulative incidence function and Gray’s test, and the associations between outcomes and different variables were estimated using a subdistribution hazard (SDH) model. Results: Comparing AVG infections with and without recurrence, PA infection was not associated with a higher risk of infection recurrence (p = 0.13); however, the first operative procedure type was associated with infection recurrence (p = 0.04). AVGs with PA infection were associated with a higher total number of surgical interventions (p < 0.05) than AVGs without PA infection. Regarding the cumulative incidences of outcomes, for AVGs treated with subtotal excision or revision, the cumulative incidence of recurrent infection was 3.3-fold higher for those with PA infection than without one year after the first surgery. However, when AVGs were treated with revision alone, the cumulative incidence was 4.1-fold. After excluding AVGs treated with total excision, the SDH model was applied, obtaining a hazard ratio for infection recurrence of 16.05 (p = 0.02) for AVGs with PA infection compared with AVGs without PA infection. No other variables were significantly associated with infection recurrence. Conclusions: For subtotal resection and revision, AVGs infected with PA had a higher recurrence rate than those infected with other species. However, revision surgery may aggravate the recurrence rate.

In this multi-institutional series, we aimed to determine the incidence, risk factors, and long-term outcomes of graft infection in patients post-femoropopliteal bypass. A multi-institutional database was retrospectively queried for all femoropopliteal bypass procedures from 1995 through 2020. Cumulative incidence function estimated the long-term rate of bypass graft infection (BGI), and the Fine-Gray model was used to determine independent risk factors for BGI to account for death as a competing risk. Over the 25-year period, 1315 femoral popliteal bypasses were identified with a median follow-up of 2.89 years (interquartile range, 0.75-6.55 years). BGI was diagnosed in 34 patients (2.6%). BGI occurred between 9 days and 11.2 years postoperatively, with a median of 109 days. Estimated 1- and 5-year incidence of BGI was 2.1% (95% confidence interval [CI], 1.4%-3.1%) and 2.8% (95% CI, 1.9%-3.9%), respectively. Medical comorbidities, indications for bypass, and popliteal bypass targets (above- vs below-knee) were similar between patients with BGI and all patients (P = not significant for each). Patients with BGI were more frequently complicated by postoperative hematoma (14.7% vs 3.7%), superficial wound infection (38.2% vs 19.2%), lymphocele/lymphorrhea (8.8% vs 2.1%), and 30-day readmission rates (47.1% vs 21.3%) (P <.05 for each). Most commonly isolated pathogens were Staphylococcus aureus (n = 19; 55.9%) and polymicrobial cultures (n = 5; 14.7%). Reoperation for BGI involved incision and drainage (n = 7; 20.6%), graft excision without reconstruction (n = 12; 35.3%), graft excision with in-line reconstruction (n = 11; 32.4%), and graft excision with extra-anatomic reconstruction (n = 2; 5.9%). Nine patients with BGI (26.5%) ultimately required major amputation. Prosthetic bypass (subdistribution hazard ratio [SHR], 3.73; 95% CI, 1.64-8.51; P =.002), postoperative hematoma (SHR, 3.44; 95% CI, 1.23-9.61; P =.018), and 30-day readmission (SHR, 2.75; 95% CI, 1.27-5.44; P =.010) were independently associated with BGI. One-year amputation-free survival was 50% (95% CI, 31.9%-65.7%) after BGI. BGI is a rare complication of femoral-popliteal bypass with significant morbidity. Graft infection is associated with the use of prosthetic grafts, postoperative hematoma, and unplanned hospital readmission. Mitigation of these risk factors may decrease the risk of this dreaded complication. [ABSTRACT FROM AUTHOR]

Abstract Vibrio metschnikovii is a widespread opportunistic pathogen that rarely causes disease in human. It caused graft infection in our case. It is important to differentiate it from another water‐transmitted pathogens.

Abstract Background So called “mycotic” aortic aneurysms account for only 0.7 to 1.3% of all aortic aneurysms and are commonly caused by Staphylococcus aureus and Salmonella species. Bacillus Calmette-Guérin (BCG), a live attenuated strain of Mycobacterium bovis, is part of the therapy of non-muscle-invasive bladder cancer (NMIBC). Case presentation We report a case series of three patients with a mycobacterial graft infection related to BCG after surgical treatment of a presumed mycotic aortic aneurysm as an extremely rare complication after NMIBC treatment. All three patients developed aortic aneurysm after BCG instillation and subsequent mycobacterial graft infection. Conclusion Diagnosis requires a high degree of suspicion because of its nonspecific symptoms and imaging. The pathogen is not detected by standard microbiological testing. Treatment includes triple antimycobacterial therapy and radical surgical interventions. Graft preservation may be considered if no anastomosis is involved.

Graft infections are associated with severe morbidity and mortality. The widespread use of the frozen elephant technique increases the incidence of complex aortic patients to suffer from graft infections. Surgery of these patients is challenging. Removal of the stent graft portion of the frozen elephant technique prosthesis via sternotomy carries the risk of irreparable damage to the descending aorta. There is currently no single-stage surgical strategy that allows for the removal of all infected material apart from a hemi-clamshell approach. This approach is technically demanding and associated with significant morbidity and mortality. This results in conservative treatment in a substantial number of patients. Pericardial tube grafts have shown to be an excellent option in treating graft infections in various aortic segments with promising results concerning freedom of re-infection and survival. We report a single-stage, trans-sternal approach to remove all infected materials and simultaneously treat the descending aorta to prevent aortic catastrophe in 2 consecutive cases. [ABSTRACT FROM AUTHOR]

Introduction: Alarming outcomes have been reported following infected endovascular aortic aneurysm repair (EVAR) device explantation. Infected fenestrated EVAR (FEVAR) exposes patients to even worse procedural risks. Report: A 67 year old man with a prior history of FEVAR presented with impaired general condition, abdominal and back pain, and increased C reactive protein. Computed tomography angiography revealed a collection around the aortic graft bifurcation and 18F-fluorodeoxyglucose–positron emission tomography (FDG-PET) revealed increased FDG uptake at this level, confirmed by labelled white blood cells, all favouring graft infection. A thoracophrenolumbotomy was performed and revealed an aorto-enteric fistula which was treated by small bowel resection. The left renal artery was transected at the distal end of the bridging stent and a thoracorenal bypass was performed. The thoracic aorta was cross clamped above the coeliac trunk for complete graft excision. Meanwhile, the right kidney was perfused with 4°C Ringer lactate solution. In situ reconstruction was accomplished with a bifurcated antimicrobial graft sutured below the superior mesenteric artery with re-implantation of the right renal artery. The patient was left with a laparostomy for definitive abdominal closure, restoration of the digestive tract, and omental wrap 72 hours later. Broad spectrum antibiotic therapy was initiated peri-operatively and reduced to sulfamethoxazole/trimethoprim for a total duration of six weeks after one sample was positive for Moraxella osloensis. Eleven months later, the patient was free from re-infection, with no fever or inflammatory syndrome. Discussion: Total explantation of stent grafts with tissue debridement and post-operative antibiotic therapy is the gold standard when dealing with infected EVAR. As with type IV thoraco-abdominal aneurysm open repair, FEVAR device explantation requires additional protective measures to prevent visceral ischaemia and renal impairment. In agreement with the European Society for Vascular Surgery guidelines, such patients should be referred to dedicated vascular centres with expertise in surgical repair, anaesthetics, and post-operative intensive care.

Aims: To discuss treatment strategies for non-traumatic, non-iatrogenic hepatic artery aneurysms (HAAs) in the presence of an arteriobiliary fistula, illustrated by a case and followed by a comprehensive review of the literature. Methods: Following the PRISMA guidelines, 24 eligible HAA cases presenting with haemobilia were identified. Characteristics of patients, aneurysms, treatment strategies and their outcomes were collected. Results: A 69 year old patient with no previous hepatobiliary intervention or trauma, presented with jaundice and haemobilia caused by a HAA. Initial treatment by endovascular stenting was chosen to prevent ischaemic liver complications. Unfortunately, this strategy failed because of stent migration due to ongoing infection leading to a type 1A endoleak. The patient had to be converted to open surgery with ligation of the HAA. The patient recovered uneventfully and no complications occurred during the following 12 months. Comprehensive literature review: Of the 24 cases, nine had a true HAA and 15 were pseudo/mycotic aneurysms, mainly caused by endocarditis or cholecystitis. The majority were located in the right hepatic artery. In 20 cases, an endovascular first approach was chosen with embolisation, none with covered stents. Three of these cases had to be converted to open surgery because of rebleeding. In all open (primary or secondary) cases, ligation of the HAA was performed. One patient in these series died. No liver ischaemia or abscesses were reported, although one patient developed an ischaemic gallbladder. Conclusions: Patients who present with a HAA and haemobilia may be treated safely by embolisation or open ligation. Using a covered stent graft in these patients can cause problems due to ongoing infection and should be monitored closely by imaging. Publication bias and lack of long term follow up imply cautious interpretation of these findings.

The optimal management of infected abdominal aortic grafts is complete surgical excision plus in situ or extra-anatomic revascularization in patients who can tolerate this morbid operation. In addition to using age and the presence of comorbidities for risk assessment, physicians form a global clinical impression when deciding whether to offer excision or to manage conservatively. Functional status is a distinct objective measure that can inform this decision. This study examines the relative impact of age and functional status on outcomes of infected abdominal aortic graft excision to guide surgical decision-making. Current Procedural Terminology code 35907 was used to identify patients undergoing excision of infected abdominal aortic graft in the 2005 to 2017 American College of Surgeons – National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified by the upper age quartile (75 years old) as a cutoff, and then by functional status, independent vs dependent (as defined by NSIQIP). The patients were then stratified into four groups: Younger (<75)/Independent, Younger (<75)/Dependent, Older (≥75)/Independent, and Older (≥75)/Dependent. Outcomes measured included 30-day mortality and major organ-system dysfunction. There were 814 patients who underwent infected abdominal aortic graft excision: 508 patients (62%) were Younger/Independent, 89 patients (11%) were Younger/Dependent, 176 patients (22%) were Older/Independent, and 41 patients (5%) were Older/Dependent. There was no statistically significant difference in 30-day mortality for Younger/Dependent (odds ratio [OR], 1.66; 95% confidence interval [CI], 0.90-3.09; P =.536) or Older/Independent (OR, 1.31; 95% CI, 0.78-2.19; P =.311) patients when compared with Younger/Independent patients, which suggests that neither old age nor dependent functional status by itself adversely affects mortality. However, when both factors were present, Older/Dependent patients had three times higher mortality when compared with Younger/Independent patients (41.5% vs 13.4%, respectively; OR, 3.13; 95% CI, 1.46-6.71; P =.003). Furthermore, as long as patients presented with independent functional status, old age by itself did not adversely affect major organ-system dysfunction (ORs for Older/Independent vs Younger/Independent were 0.76 [ P =.454], 1.04 [ P =.874], and 0.90 [ P =.692] for cardiac, pulmonary, and renal complications, respectively). On the contrary, even in younger patients, dependent functional status was significantly associated with higher pulmonary complications (Younger/Dependent vs Younger/Independent: OR, 2.22; 95% CI, 1.33-3.73; P =.002) and higher rates of unplanned reoperation (OR, 2.67; 95% CI, 1.62-4.41; P <.0001). Dependent functional status has significant association with adverse outcomes after excision of infected abdominal aortic grafts, whereas old age alone does not. Therefore, this procedure could be considered in appropriately selected elderly patients with otherwise good functional status. However, caution should be applied in dependent patients regardless of age due to the risk of pulmonary complications. [ABSTRACT FROM AUTHOR]

Background: An aortic graft implantation is an effective therapeutic method for various aortic diseases. However, it is known that sometimes these implanted grafts can be the foci of infections. Here we report a rare case of graft infection that presented multiple embolisms of aortic branches and peripheral organs.Case Presentation: A 63-year-old Japanese woman with a history of aortic graft implantation presented with occlusions of large arteries in different loci and time points, with elevation of non-specific inflammatory markers. Thoracic contrast-computed tomography (CT) captured vegetation in the descending aortic graft and the [18F]fluorodeoxyglucose positron emission tomography/computed tomography ([18F]FDG PET/CT) showed accumulation of FDG in the same site, suggesting a graft infection. Despite all these suspicious findings, repeated blood culture examinations never detected any microorganisms. A diagnosis of Aspergillus graft infection was made based on an elevated serum β-D glucan (βDG) and a positive Aspergillus galactomannan (GM) antigen test. The patient subsequently had surgery with replacement of the descending aortic graft and anti-fungal drugs were instituted with significant improvement noted.Conclusion: In the present case, the patient's specific feature in the anatomical vascular construction, past operation, and basal fundamental diseases collaboratively contributed to the pathogenesis of the present infection. It is important to recognize the risk of graft infection and conduct imaging studies when indicative symptoms emerge. The negativity in blood culture studies often makes detection of pathogenic microbes extremely difficult. This case suggests that non-cultural tests such as bDG and GM can be useful for diagnosis and starting appropriate anti-fungal drugs in the early stages. [ABSTRACT FROM AUTHOR]

Aortic prosthesis infection is a devastating complication of aortic surgery. In situ reconstruction with the neo-aorto-iliac system (NAIS) bypass technique has become increasingly used and is recommended in recent treatment guidelines. The main aim was to evaluate NAIS procedural outcomes when undertaken after previous open or endovascular aortic repair in Sweden. In this retrospective study, The National Quality Registry for Vascular Surgery (Swedvasc) was used to identify Swedish centres that offered the NAIS bypass procedure for aortic prosthesis infection between 2008 and 2018. Variables of special interest were procedural details, short and long term survival, renal and other complications, and the durtion of antimicrobial treatment. Forty patients (36 males, four females [mean age 69 years], 32 open repairs, seven endovascular aortic repairs [EVAR] and one fenestrated EVAR; 21 presented with aorto-enteric fistula) operated on with NAIS bypass were reviewed. The median time from the primary aortic intervention to the NAIS bypass procedure was 32 months (range 0 – 252 months). Mean ± standard deviation operating time was 645 ± 160 minutes, mean blood loss was 6 277 ± 6 525 mL, mean length of intensive care unit stay was 5.3 ± 3.7 days, and mean length of overall hospital stay was 21.2 ± 11.4 days. Thirty-five patients (88%) had a positive microbial culture; the most commonly isolated pathogen was Candida spp. The majority of patients survived for 30 days (n = 35 [88%]), and 33 (83%) and 32 (80%) patients survived for 90 days and one year, respectively. The number of surviving patients free from antimicrobial treatment at 90 days, six months, and one year was 19 (58%), 29 (88%), and 30 (94%). After a mean long term follow up of 69.9 ± 44.7 months, 20 patients were still alive. The NAIS bypass procedure offered reasonable survival and functional outcomes, and was associated with a high cure rate, defined as freedom from any antimicrobial treatment. [ABSTRACT FROM AUTHOR]

Acute limb ischemia of the upper extremity is less frequently encountered than in the lower extremity. The etiology is typically cardioembolic. Axillary-femoral stump syndrome is a rare complication associated with an occluded axillary-femoral bypass graft. We present the case of recurrent acute limb ischemia of the upper extremity whose embolic source was a retained cuff of a previously explanted axillary-profunda bypass graft. The patient failed anticoagulation after an initial embolectomy and after a recurrent embolism from the retained cuff, ultimately required cuff exclusion with a covered stent.

Patients who have undergone revascularization with a cryopreserved cadaveric arterial allograft (CCAA) require lifelong surveillance because of the risk of allograft failure. The reported long-term complications of these grafts include thrombosis, anastomotic pseudoaneurysm, and graft disruption. We have described a case in which a CCAA developed a nonanastomotic pseudoaneurysm at the site of a previously ligated branch vessel and was repaired using a covered stent graft. This case demonstrates that spontaneous rupture of CCAA branches is a late complication that can occur when using these grafts and that endovascular methods are an option for repair.

Background Patients with Darier disease often present with staphylococcal skin infections and are at risk for complications when they undergo cardiothoracic surgery, such as acute aortic dissection repair. Case summary A 39-year-old woman with hypertension and Darier disease suffered an acute type A aortic dissection, requiring emergency operation with a Dacron graft. Twenty-five days post-operatively, she developed pneumonia and staph hominis was isolated in blood cultures and Bronchoalveolar Lavage. Following completion of antibiotics, multiple relapses occurred during a 6-month period, each time treated with appropriate antibiotic therapy. An 18F-fluorodeoxyglucose positron emission tomography computerized tomography showed persistent graft uptake and re-operation was performed. At 22 months of follow-up, the patient remains asymptomatic and the 18F-FDG PET/CT shows significant reduction in FDG uptake. Discussion Graft infection is a rare but serious complication. Antibiotic therapy is often inadequate and re-operation is needed. As staphylococcal skin infections often occur in patients with Darier disease, adequate preprocedural skin preparation and sterilization are very important in these patients. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Our aim was to evaluate the mid-term outcomes of bovine pericardial tube graft repair for infectious aortic disease in any aortic segment. METHODS Between May 2015 and July 2020, 45 patients were treated for infectious aortic disease of the native (n  = 9) aorta or after (endo-)graft (n  = 36) implantation with bovine pericardial tube grafts. Clinical, infectious details, outcomes and follow-up data were evaluated. RESULTS All aortic segments underwent pericardial tube graft or bifurcational replacement: the aortic root (n  = 12, 27%), ascending aorta (n  = 18, 40%), aortic arch (n  = 7, 16%), descending aorta (n  = 5, 11%), thoraco-abdominal aorta (n  = 6, 13%) and abdominal aorta (n  = 18, 40%) including the iliac arteries (n  = 14, 31%). Organ fistulation (n  = 15, 33%) was the most common underlying pathology. Seven patients (16%) expired in-hospital secondary to ongoing sepsis (n  = 5, 11%), respiratory failure (n  = 1, 2%) and unknown cause (n  = 1, 2%). A fungal infection was predictive for in-hospital mortality (P  = 0.026, odds ratio: 19.470). After a median follow-up of 11 [first quartile: 2, third quartile 26] months, 9 additional patients (20%) expired and 1 patient developed a postoperative spondylodiscitis at the level of the aortic tube graft. Hence, freedom from proven aortic graft re-infection was 98%. CONCLUSIONS Orthotopic aortic reconstruction using bovine pericardial tube grafts to treat infectious aortic disease is possible in any aortic segment. Organ fistulation is a frequently observed disease mechanism requiring concomitant treatment. Granted, the early attrition rate is substantial, but after the initial period, both survival and freedom from re-infection appear encouraging. [ABSTRACT FROM AUTHOR]

Vibrio metschnikovii is a widespread opportunistic pathogen that rarely causes disease in human. It caused graft infection in our case. It is important to differentiate it from another water‐transmitted pathogens. [ABSTRACT FROM AUTHOR]

Background: So called "mycotic" aortic aneurysms account for only 0.7 to 1.3% of all aortic aneurysms and are commonly caused by Staphylococcus aureus and Salmonella species. Bacillus Calmette-Guérin (BCG), a live attenuated strain of Mycobacterium bovis, is part of the therapy of non-muscle-invasive bladder cancer (NMIBC).Case Presentation: We report a case series of three patients with a mycobacterial graft infection related to BCG after surgical treatment of a presumed mycotic aortic aneurysm as an extremely rare complication after NMIBC treatment. All three patients developed aortic aneurysm after BCG instillation and subsequent mycobacterial graft infection.Conclusion: Diagnosis requires a high degree of suspicion because of its nonspecific symptoms and imaging. The pathogen is not detected by standard microbiological testing. Treatment includes triple antimycobacterial therapy and radical surgical interventions. Graft preservation may be considered if no anastomosis is involved. [ABSTRACT FROM AUTHOR]

Meningitis due to Staphylococcus aureus is extremely rare, with an annual incidence of 1-3%. In this report, we present a rare case involving meningitis, an infected graft, and an infected fluid collection with two forms of S. aureus in a patient who received a bovine brain graft status post-decompression and suboccipital craniectomy with C1 laminectomy and duraplasty for Chiari malformation. The treatment approach included surgical debridement and graft retention, followed by an extended course of antibiotic treatment with oxacillin and rifampin. The patient successfully completed 12 weeks of total antibiotic therapy and was transitioned to suppressive therapy indefinitely with cefadroxil. This case highlights the importance of prompt identification and treatment of S. aureus meningitis due to the high mortality associated with this disease., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Ahmed et al.)

Prosthetic vascular graft infection is one of the most severe vascular surgery complications. Fibrin gel (FG) has many useful characteristics as biocompatibility, biodegradation, adhesion, and haemostasis to develop the local antibiotic delivery system. In this study, human plasma was collected from peripheral blood that was used to create fibrin gel by supplement ion Ca2+. Antibiotic-containing fibrin gel was then evaluated in some characteristics such as surface structure, biodegradation, antibiotic delivery, cytotoxicity, and bacterial biofilm prevention in vitro and in vivo. The results showed that fibrin gel was excellent material for the extended delivery of antibiotics. Most importantly, antibiotic-containing fibrin gel was not toxic for human fibroblast cells in vitro and inhibited bacterial biofilm growth in vitro and in vivo. This research is the first step in developing an antibiotic delivery system for effective graft infection treatments. [ABSTRACT FROM AUTHOR]

• Case report of 35 year old patient with arteriovenous graft formation (AVG). • Multiple interventions performed with successful salvage over a course of 5 years. • Outline of role of arteriovenous grafts and current literature and recommendations. • The learning point from our case is that close monitoring and surveillance can lead to a prolongation of an active AVG. Arteriovenous grafts (AVG) is a good alternative when native arteriovenous fistula (AVF) is not possible. However, complications are higher and close surveillance is required for successful salvage intervention. We present the case of a 35 year old man with a history of a successful Brachio-Axillary AVG performed in his right arm in 2012. He had a background of multiple previous failed attempts of a native AVF formation. He presented in 2014 with symptoms consistent with AVF stenosis. He underwent a successful fistuloplasty and 2 stent insertion. In June 2015 he presented again with re-stenosis and successful fistuloplasty was performed with balloon dilatation. In October 2015 he presented with AVF thrombosis. This was treated with fistuloplasty and thrombolysis. He presented again in August 2016 with a recurrent thrombosis in his AVG and this was again treated with a successful fistuloplasty and thrombolysis on two separate occasions. He then presented in September 2016 with re-stenosis. This was treated with fistuloplasty and 2 stent insertion. He underwent a successful renal transplant during this time and presented again with a sinus discharge in February 2019 when the plan was made for subtotal graft excision. Incidence of complications is higher when a graft is used over a native AVF. However, close surveillance and prompt intervention can lead to multiple successful salvage procedures thus prolonging the lifespan of the graft. As in our case we were able to prolong the lifespan of the AVG with multiple successful interventions. [ABSTRACT FROM AUTHOR]

Infected arteriovenous grafts necessitate intervention to obtain source control. However, excising the graft material can be challenging and can lead to complications. Leaving a cuff of graft at the sites of anastomosis allows for the avoidance of potential risks. However, it is unclear whether doing so places patients at risk of recurrent graft infection. The purpose of the present study was to investigate the effect of complete vs partial excision of infected arteriovenous prosthetic dialysis access grafts. The data from all patients who had undergone surgical intervention for infected arteriovenous grafts at a single institution were retrospectively reviewed. The patients were grouped according to intervention type: complete excision and partial excision of arteriovenous prosthetic grafts. Partial excisions were further substratified based on whether flow had been restored through the arteriovenous access. The primary outcome was freedom from subsequent intervention for infection, defined as the number of days from excision to subsequent reoperation for reinfection. Freedom from infection was analyzed using the Kaplan-Meier method. A total of 117 patients had undergone surgical intervention for 122 infected arteriovenous grafts from 2003 to 2016. Of these 117 patients, 79 (64.8%) had undergone partial excision of infected arteriovenous grafts, and 43 (35.2%) had undergone complete excision with vascular repair. Within the partial excision cohort, 71 infected arteriovenous grafts (58.2%) were not flow restored and 8 (6.6%) were flow restored using either prosthetic or autogenous interpositions. The median follow-up time was 2.4 years (interquartile range, 0.6-4.5 years). The most common causative organisms included methicillin-resistant Staphylococcus aureus (n = 34; 27.9%), methicillin-sensitive S. aureus (n = 17; 13.9%), and S. epidermidis (n = 15; 12.3%). The recurrent infection rate in the partial excision group was 16.5% (n = 13) compared with 2.3% (n = 1) in the complete excision group. In the flow-restored subcohorts, those with restoration using prosthetic interposition grafts had the greatest reinfection rate at 57.1% (n = 4), and those with restoration using autogenous conduits did not experience reinfection (P =.033). Incomplete excision of infected arteriovenous prosthetic grafts was associated with a higher rate of reinfection compared with complete graft excision. Complete excision presents technical challenges but could provide superior source control in managing infected dialysis access. Complete excision with vascular reconstruction should be performed when possible to avoid leaving remnant prosthetic material. [ABSTRACT FROM AUTHOR]

• Immunosuppressed patients may not display typical clinical or biochemical features associated with mycotic aneurysms. • Clinicians should have a high index of suspicion for infective aetiology when treating aneurysmal disease in immunocompromised patients. • It is important to obtain intraoperative tissue samples for histopathology and microbiological assessment in immunocompromised patients for detection of rare pathogens. • Autogenous vein should be used in infected surgical fields to avoid the risk of prosthetic graft infection. Mycotic aneurysms are an uncommon occurrence, with Staphylococcus and Salmonella species found to be the causative pathogen in up to 95% of cases. We believe this is the first described case of a common femoral artery mycotic aneurysm due to Listeria monocytogenes. A 66-year-old male presented with a two-month history of an increasing painful mass in his left groin, on the background of immunosuppression treatment for ankylosing spondylitis. He was afebrile on assessment, with a normal white cell count. Contrast enhanced CT scan showed a common femoral artery aneurysm, with no infective features. His aneurysm was excised and repaired with a Dacron tube graft. L. monocytogenes was cultured from the aneurysm tissue, and he was commenced on appropriate antibiotic treatment. The prosthetic graft was also replaced with a venous bypass of the aneurysm. L. monocytogenes is a rare cause of mycotic aneurysm with less than 40 cases reported in the literature. Immunosuppression is a recognised risk factor for Listerial infections. Immunocompromised patients may not display typical clinical or biochemical features associated with a mycotic aneurysm. Prosthetic graft infections are associated with significant mortality, with excision of the prosthetic material and venous reconstruction associated with good outcomes for eradicating infection. This report highlights the importance of obtaining intraoperative tissue samples for microbiological and histopathological assessment in immunocompromised patients. This is important for the detection of rare organisms such as L.monocytogenes , requiring targeted antibiotic therapy. Inappropriate treatment of Listerial infections can result in serious invasive illness. [ABSTRACT FROM AUTHOR]

The purpose of this study is to introduce the aortic bulge sign, a finding observed retrospectively on computed tomography prior to the acute presentation of aortoenteric fistula, and to determine its interobserver reliability. Following research ethics board approval, all cases of aortoenteric fistula at our institution occurring from 2011–2015 were identified retrospectively. All previous computed tomography images of patients who eventually developed aortoenteric fistula were reviewed by a single observer for the presence of a potentially predictive finding of fistulization, the aortic bulge sign. These previous images were then combined with age and sex matched controls into a case bank. Eight radiology residents and staff were instructed in observing the aortic bulge sign. These observers then reviewed the case bank in a blinded analysis to determine the interobserver reliability of this finding. Fourteen cases of aortoenteric were identified. The average patient age was 70.71 years with a male-to-female ratio of 11:3. Eleven patients had previous computed tomography images available for review. With blinded analysis by multiple observers, the aortic bulge sign was identified with greater than 80% agreement in six of 11 cases (66.67%). Fleiss' kappa was calculated at k = 0.60 (95% confidence interval 0.50–0.69), corresponding to moderate-to-substantial interobserver agreement. The aortic bulge sign has been retrospectively identified as a promising computed tomography finding of eventual aortoenteric fistula prior to acute presentation. Further study is required to determine the diagnostic value of this sign. [ABSTRACT FROM AUTHOR]

Introduction: Split skin grafting is widely used surgical procedure for the treatment of ulcers. Graft survival depends on number of factors like vascularity, wound infection etc. diabetes is associated with endothelial dysfunction, neuropathy, wound infection which collectively affect the graft survival. Aim: To compare the amount of graft uptake, the post operative complications and survival of split thickness skin graft in diabetic and non diabetic wound management. Materials and Methods: In our prospective nonrandomized comparative study total 104 patients with ulcer were included of which 52 were diabetic and 52 were non-diabetic. All of them underwent split skin grafting as part of their wound management. Comparison was made between two groups in terms of amount of graft uptake, post operative wound infection, re-ulceration, revisional surgery, donor site infection. Results: Average wound surface area in diabetic group is 42.31 cm2 and average graft uptake is 23.67 cm2 , in non-diabetic group average wound surface area is 78.06 cm2 and average graft uptake is 64.06 cm2 . Compared with non-diabetics, diabetics have significantly less graft uptake (p0.3, not significant). 13(25%) out of 52 in diabetic group developed post operative graft infection, 7(13.5%) out of 52 in non-diabetic group developed graft infection (p > 0.1, not significant). None of the patients in the study developed donor site infection. Conclusion: Diabetes is associated with poor graft survival and high post operative complication rates in patients undergoing split skin grafting.

Purpose.: The treatment of infectious aortic disease is still challenging with open surgical debridement and reconstruction using biological, preferably autologous material, being the treatment of choice. However, these procedures are associated with high morbidity and mortality. Endovascular therapy is often considered a bridging method only, since the biologically inactive fabric of the covered stent grafts usually cannot be treated sufficiently with anti-infective agents in the event of a (obligate) consecutive secondary graft infection. This study aims to prove the feasibility of a physician-made pericardium stent graft ex-vivo., Technique.: A state-of-the-art TEVAR was modified by separating the fabric from the z-stents and suturing a hand-sewn bovine pericardium tube to the bare metal. Feasibility of preparation, re-sheathing, and delivery is demonstrated in an ex-vivo model., Conclusion.: This first xenogeneic stent graft could be manufactured and deployed successfully. In the future this may provide a bridging alternative for high-risk patients with infected native aortic aneurysm or aortic fistulas, eventually followed by surgical or thoracoscopic/laparoscopic debridement. Further studies on simulators or animal models are needed to test the technique and investigate its long-term durability. Additionally, this study prompts reflection on whether materials currently used should be further developed to prevent graft infections., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Benedikt Reutersberg is a proctor for Terumo aortic and Cook medical. Alexander Zimmermann is a proctor for Artivion, Terumo Aortic, Cook Medical, Lombard/Endovastec/Microport and iVascular. He is member of an Advisory Board for Medtronic, Artivion, and iVascular. Albert Busch and Lorenz Meuli declare no conflict of interest.

In this study, we report a unique case of aorto-bifemoral graft infection, which developed in a 47-year-old male patient after endovascular aortic aneurysmal repair (EVAR) and extra anatomic axillo-femoral bypass. The patient had previously been treated by EVAR for an infrarenal abdominal aortic aneurysm. Earlier, the EVAR was blocked by a thrombosis and treated with an extra-anatomic axillo femoral bypass, which then became occluded. The patient was then treated with an aorto-bifemoral bypass using a Dacron Y graft. A few months later, he was referred to our cardiovascular center with high body temperature, weight loss, inability to stand and walk, and very serious sepsis. A computed abdominal tomography scan revealed that a part of the graft proximal to the bifurcation had totally eroded into the proximal jejunum. We treated this patient with multiple surgeries, antibiotic administrations and hypochlorous acid irrigation without graft excision, which carries a high morbidity and mortality risks. [ABSTRACT FROM AUTHOR]

• Aortoesophageal fistula (AEF) after TEVAR is a rare but challenging complication associated with high mortality rates. • AEF after TEVAR has to be treated in an interdisciplinary concept. • If stent removal is not feasible, a multi-stage surgical procedure with leaving the thoracic stent graft in situ can lead to infection remediation. Aortoesophageal fistula (AEF) after thoracic endovascular aortic repair (TEVAR) is a rare complication associated with high mortality. Most well established treatment is multi-staged surgery, including removal of infected stent graft, esophageal resection and aortic reconstruction. We report on a case of a 67-year-old patient with AEF and stent graft infection. Stent removal was infeasible due to the critical condition of the patient and history of multiple vascular procedures of the thoracoabdominal aorta. Surgical management included staged right and left thoracotomy, esophagectomy, vacuum therapy (VAC) on stent prosthesis and subsequent graft coverage with omental and pleural flaps, followed by esophageal reconstruction. An established and generally accepted treatment approach for graft infections does not exist. Graft explantation and radical surgical debridement is the therapy of choice for prosthetic infections. In comparison to previous literature, our case represents the complexity of the treatment of AEF and its enormous demands on the interdisciplinary medical team. Our report shows that in an emergency situation without other surgical options as in our case, it was possible to stabilize the patient through application of vacuum therapy in the infected area, with simultaneous esophagectomy, followed by secondary staged reconstruction with omentoplasty and pleura parietalis flap remaining the graft in situ. [ABSTRACT FROM AUTHOR]

Aortic and iliac graft infections remain complex clinical problems with high mortality and morbidity. Cryopreserved arterial allografts (CAAs) and rifampin-soaked Dacron (RSD) are options for in situ reconstruction. This study aimed to compare the safety and effectiveness of CAA vs RSD in this setting. Data from patients with aortic and iliac graft infections undergoing in situ reconstruction with either CAA or RSD from January 2002 through August 2022 were retrospectively analyzed. Our primary outcomes were freedom from graft-related reintervention and freedom from reinfection. Secondary outcomes included comparing trends in the use of CAA and RSD at our institution, overall survival, perioperative mortality, and major morbidity. A total of 149 patients (80 RSD, 69 CAA) with a mean age of 68.9 and 69.1 years, respectively, were included. Endovascular stent grafts were infected in 60 patients (41 CAA group and 19 RSD group; P ≤.01). Graft-enteric fistulas were more common in the RSD group (48.8% RSD vs 29.0% CAA; P ≤.01). Management included complete resection of the infected graft (85.5% CAA vs 57.5% RSD; P ≤.01) and aortic reconstructions were covered in omentum in 57 (87.7%) and 63 (84.0%) patients in the CAA and RSD group, respectively (P =.55). Thirty-day/in-hospital mortality was similar between the groups (7.5% RSD vs 7.2% CAA; P = 1.00). One early graft-related death occurred on postoperative day 4 due to CAA rupture and hemorrhagic shock. Median follow-up was 20.5 and 21.5 months in the CAA and RSD groups, respectively. Overall post-discharge survival at 5 years was similar, at 59.2% in the RSD group and 59.0% in the CAA group (P =.80). Freedom from graft-related reintervention at 1 and 5 years was 81.3% and 66.2% (CAA) vs 95.6% and 92.5% (RSD; P =.02). Indications for reintervention in the CAA group included stenosis (n = 5), pseudoaneurysm (n = 2), reinfection (n = 2), occlusion (n = 2), rupture (n = 1), and graft-limb kinking (n = 1). In the RSD group, indications included reinfection (n = 3), occlusion (n = 1), endoleak (n = 1), omental coverage (n = 1), and rupture (n = 1). Freedom from reinfection at 1 and 5 years was 98.3% and 94.9% (CAA) vs 92.5% and 87.2% (RSD; P =.11). Two (2.9%) and three patients (3.8%) in the CAA and RSD group, respectively, required graft explantation due to reinfection. Aorto-iliac graft infections can be managed safely with either CAA or RSD in selected patients for in situ reconstruction. However, reintervention was more common with CAA use. Freedom from reinfection rates in the RSD group was lower, but this was not statistically significant. Conduit choice is associated with long-term surveillance needs and reinterventions. [ABSTRACT FROM AUTHOR]

We compared association of Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa and Enterococcus faecalis with nine vascular implants after co-culture. Vascular implants were composed of various materials such as warp knitted polyester (with or without gelatin and silver ions), expanded polytetrafluoroethylene and biological materials – surface treated porcine pericardial patch and Omniflow II. The lowest overall number of associated bacteria was detected for polytetrafluoroethylene implants and porcine pericardial patch. The highest overall number of associated bacteria was detected for Omniflow II implant. The major source of variation, i.e. primary factor influencing colonization, is the implant type (56.22%), bacterial species is responsible for only 1.81%, and interaction of those two factors – 13.09% of variation.