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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., Highlights In patients presenting with haemobilia in the presence of a non-traumatic and non-iatrogenic hepatic artery aneurysm•Endocarditis and cholecystitis are the most common causes•The main treatment modality is embolisation•Liver ischaemia and liver abscesses have not been reported after treatment•Close surveillance is recommended as the area has to be considered contaminated•Treatment should be performed by a multidisciplinary team

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.

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., Highlights • Alarming outcomes have been reported following infected endovascular aortic aneurysm repair (EVAR) explantation. • Total explantation of stent grafts with tissue debridement and post-operative antibiotic therapy is the gold standard. • FEVAR explantation requires additional protective measures to prevent visceral ischaemia and kidney impairment.

Purpose: To investigate the physiological uptake of hybrid fluorine-18-fluorodeoxyglucose (FDG)–positron emission tomography/computed tomography (PET/CT) before and after an uncomplicated endovascular aneurysm sealing (EVAS) procedure as a possible tool to diagnose EVAS graft infection and differentiate from postimplantation syndrome. Materials and Methods: Eight consecutive male patients (median age 78 years) scheduled for elective EVAS were included in the prospective study ( ClinicalTrials.gov identifier NCT02349100). FDG-PET/CT scans were performed in all patients before the procedure and 6 weeks after EVAS. The abdominal aorta was analyzed in 4 regions: suprarenal, infrarenal neck, aneurysm sac, and iliac. The following parameters were obtained for each region: standard uptake value (SUV), tissue to background ratio (TBR), and visual examination of FDG uptake to ascertain its distribution. Demographic data were obtained from medical files and scored based on reporting standards. Results: Visual examination showed no difference between pre- and postprocedure FDG uptake, which was homogenous. In the suprarenal region no significant pre- and postprocedure differences were observed for the SUV and TBR parameters. The infrarenal neck region showed a significant decrease in the SUV and no significant decrease in the TBR. The aneurysm sac and iliac regions both showed a significant decrease in SUV and TBR between the pre- and postprocedure scans. Conclusion: Physiological FDG uptake after EVAS was stable or decreased with regard to the preprocedure measurements. Future research is needed to assess the applicability and cutoff values of FDG-PET/CT scanning to detect endograft infection after EVAS.

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.

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.

Highlights • 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., Introduction 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. Presentation of case 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. Conclusion 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.

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

Objective 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. Methods 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. Results 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. Conclusion 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.

Objectives: This study aimed to evaluate early- and long-term outcomes in patients who undergo muscle flap coverage (MFC) for prosthetic graft infections (PGIs) at the groin or thigh. Materials and Methods: We retrospectively retrieved and analyzed data on infected wound cures, recurrence, graft and limb salvage, and survival of patients who underwent MFC for PGI at the groin or thigh between 2000 and 2018. Results: There were eight patients in our cohort: six had groin PGIs and two had thigh PGIs. Moreover, of these patients, seven were treated from sartorius muscles and one from a gracilis muscle. The indicated wounds healed in all eight patients, but two patients died during hospitalization. Three patients suffered recurrence within 8 months, one of which overcame the infection and achieved wound cure without graft removal, with negative pressure wound therapy. No patients lost their limbs during the follow-up term (mean, 24 months; range, 1-60 months). Finally, four patients (50%) survived without removal of the infected graft for longer than 2 years. Conclusion: MFC can be a curative treatment for PGI, but there remains a possibility of a recurring infection thereafter.

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.

Summary. Background: Prosthetic vascular graft infection (PVGI) is a complication with high mortality. Cyanoacrylate (CA) is an adhesive which has been used in a number of surgical procedures. In this in-vivo study, we aimed to evaluate the relationship between PVGI and CA. Materials and methods: Thirty-two rats were equally divided into four groups. Pouch was formed on back of rats until deep fascia. In group 1, vascular graft with polyethyleneterephthalate (PET) was placed into pouch. In group 2, MRSA strain with a density of 1 ml 0.5 MacFarland was injected into pouch. In group 3, 1 cm 2 vascular graft with PET piece was placed into pouch and MRSA strain with a density of 1 ml 0.5 MacFarland was injected. In group 4, 1 cm 2 vascular graft with PET piece impregnated with N-butyl cyanoacrylate-based adhesive was placed and MRSA strain with a density of 1 ml 0.5 MacFarland was injected. All rats were scarified in 96th hour, culture samples were taken where intervention was performed and were evaluated microbiologically. Bacteria reproducing in each group were numerically evaluated based on colony-forming unit (CFU/ml) and compared by taking their average. Results: MRSA reproduction of 0 CFU/ml in group 1, of 1410 CFU/ml in group 2, of 180 200 CFU/ml in group 3 and of 625 300 CFU/ml in group 4 was present. A statistically significant difference was present between group 1 and group 4 (p < 0.01), between group 2 and group 4 (p < 0.01), between group 3 and group 4 (p < 0.05). In terms of reproduction, no statistically significant difference was found in group 1, group 2, group 3 in themselves. Conclusions: We observed that the rate of infection increased in the cyanoacyrylate group where cyanoacrylate was used. We think that surgeon should be more careful in using CA in vascular surgery.

Highlights • 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., Introduction Mycotic aneurysms are an uncommon occurrence, withStaphylococcus 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. Presentation of case 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. Discussion 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. Conclusion 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.

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.

Prosthetic vascular bypass graft infection is a rare complication requiring prompt identification and isolation of the organism. A 66-year-old woman developed left lower extremity pain and a pulsatile pseudoaneurysm 7 months after left common femoral to peroneal artery bypass with prosthetic polytetrafluoroethylene graft, requiring re-exploration and a jump graft. Pasteurella multocida was isolated from blood and tissue culture specimens, and the patient admitted to a new kitten that frequently bit her lower extremities. Treatment included intravenous administration of ertapenem for 6 weeks followed by lifelong oral antibiotic suppression, which may offer the best chance for limb salvage when total graft explantation would result in amputation. Keywords: Pseudoaneurysm, Pasteurella multocida, Graft infection, Vascular bypass graft

Objective To report the early and mid-term outcomes following open surgical conversion (OSC) after failed endovascular aortic repair (EVAR) using data from a multicentric registry. Methods A retrospective study was carried out on consecutive patients undergoing OSC after failed EVAR at eight tertiary vascular units from the same geographic area in the North-East of Italy, from April 2005 to November 2019. Study endpoints included early and follow-up outcomes. Results A total of 144 consecutive patients were included in the study. Endoleaks were the most common indication for OSC (50.7%), with endograft infection (24.6%) and occlusion (21.9%) being the second most prevalent causes. The overall rate of 30-day all-cause mortality was 13.9% (n = 20); 32 patients (22.2%) experienced at least one major complication. Mean length of stay was 13 ± 12.7 days. On multivariate logistic regression, age (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.01-1-19; P = .02), renal clamping time (OR, 1.07; 95% CI, 1.02-1.13; P = .01), and suprarenal/celiac clamping (OR, 6.66; 95% CI, 1.81-27.1; P = .005) were identified as independent predictors of perioperative major complications. Age was the only factor associated with perioperative mortality at 30 days. Renal clamping time >25 minutes had sensitivity of 65% and specificity of 70% in predicting the occurring of major adverse events (area under the curve, 0.72; 95% CI, 0.61-0.82). At 5 years, estimated survival was significantly lower for patients treated due to aortic rupture/dissection (28%; 95% CI, 13%-61%), compared with patients in whom the indication for treatment was endoleak (54%; 95% CI, 40%-73%), infection (53%; 95% CI, 30%-94%), or thrombosis (82%; 95% CI, 62%-100%; P = .0019). Five-year survival rates were significantly lower in patients who received emergent treatment (28%; 95% CI, 14%-55%) as compared with those who were treated in an urgent (67%; 95% CI, 48%-93%) or elective setting (57%; 95% CI, 43%-76%; P = .00026). Subjects who received suprarenal/celiac (54%; 95% CI, 36%-82%) or suprarenal (46%; 95% CI, 34%-62%) aortic cross-clamping had lower survival rates at 5 years than those whose aortic-cross clamp site was infrarenal (76%; 95% CI, 59%-97%; P = .041). Using multivariate Cox proportional hazard, older age and emergency setting were independently associated with higher risk for overall 5-year mortality. Conclusions OSC after failed EVAR was associated with relatively high rates of early morbidity and mortality, particularly for emergency setting surgery. Endoleaks with secondary sac expansion were the main indication for OSC, and suprarenal aortic cross-clamping was frequently required. Endograft infection and emergent treatment remained associated with poorer short- and long-term survival.

Objective: The aim of this retrospective cohort study was to investigate the outcome of rectus femoris muscle flaps (RFFs) for deep groin wound complications in vascular surgery patients and to compare the outcome with a cohort of sartorius muscle flaps (SMFs) because the RFF is a promising alternative technique for groin coverage.Methods: All RFFs and SMFs performed by vascular surgeons in a regional collaboration in The Southern Netherlands were retrospectively reviewed. Primary outcomes were muscle flap survival, overall and secondary graft salvage, and limb salvage. Secondary outcomes were 30-day groin wound complications and mortality, donor site and vascular complications, 1-year amputation-free survival, overall patient survival, impaired knee extensor function, and length of hospital stay.Results: A total of 96 RFFs were performed in 88 patients (mean age, 68 years; 67% male) and compared with a cohort of 30 SMFs in 28 patients (mean age, 64 years; 77% male). At a mean follow-up of 29 months and 23 months, respectively, comparable flap survival (94% vs 90%), secondary graft salvage (80% vs 92%), and limb salvage (89% vs 90%) rates were found. The 30-day mortality rates were 12% and 17%, respectively, and the 1-year amputation-free survival was comparable between treatment groups (71% vs 68%).Conclusions: This study presents a large series of RFFs for deep groin wound complications after vascular surgery. We demonstrate that muscle flap coverage using the rectus femoris muscle by vascular surgeons is an effective way to manage complex groin wound infections in a challenging group of patients, achieving similarly good results as the SMF.

Abdominal aortic graft infections (AGIs) occur in 1-5% of aortic prosthetic placements. It can result in limb amputation, pseudo-aneurysm formation, septic emboli, aorto-enteric fistulae, septic shock and death. The most frequently involved pathogens are methicillin-susceptible Staphylococcus aureus, methicillin-resistant Staphylococcus aureus and coagulase-negative staphylococci, followed by Enterobacteriaceae and uncommon bacteria. In case of gut involvement the presence of fungi has to be considered. Computed tomography angiography is actually the gold standard diagnostic imaging but magnetic resonance is a valid alternative. Nuclear medicine imaging is commonly used to improve sensitivity and specificity. Signs and symptoms are often aspecific and blood cultures can be negative, requiring alternative ways to detect the microorganism responsible for infection, such as 16S rRNA gene sequencing and molecular rapid diagnostic tests. Curative surgical intervention is the first choice approach, with in-situ reconstruction providing by far the best outcome and xenopericardial bovine patch as a promising option. For patients unable to undergo major surgery, the outcome of conservative approach remains uncertain but usually provides for life-long suppressive therapy. However, in selected cases an attempt of stopping antibiotic treatment after 3-6 months can be done. Given the difficulty in their management, we performed a review of AGIs, in order to raise awareness on clinical presentation, current available diagnostic tools, prophylaxis, surgical and anti-infective treatment of AGIs.

Aorto-enteric fistulae pose a challenging negative outcome of aortic intervention. Treatment involves graft excision, and recently, more enthusiasm has met in situ revascularization over extra-anatomic bypass. This has been traditionally performed through the transperitoneal approach via a midline abdominal incision. We propose an exclusively total retroperitoneal technique in managing this complication with regard to both the vascular and alimentary tract technical aspects of the procedure. This involves exclusion and bypass of the affected segment followed by en-mass resection of the affected segment with the duodenum, and finally, bowel anastomosis. We present a case of an aorto-enteric fistulae illustrating classical radiological findings treated via a flank incision and retroperitoneal technique after a temporizing endovascular stent placement at an outside institution. Peri-operative course was uneventful. The retroperitoneal approach has been shown to be equivalent to its transperitoneal counterpart in many aspects of treating aortic disease. It has also been shown to be superior in others, including but not limited to, faster return of bowel function, decreased respiratory complications, less blood loss and shorter length of stay in the intensive care unit (ICU) and hospital. We recommend adding this approach to every vascular surgeons operative armamentarium when it comes to managing aorto-enteric fistulae. This might be especially helpful in avoiding re-operative planes, thus minimizing blood loss and iatrogenic bowel injury, better aortic exposure, and adequate access to the duodenum.

Objective Once a replaced prosthetic graft is infected, it is usually necessary to re-replace the thoracic aorta to achieve complete resolution of the infection. It is, however, an exceedingly invasive approach to perform such a repeat surgery on patients in a poor condition. We have managed both re-replacement of an infected prosthetic graft and conservative therapy with vacuum-assisted wound closure (VAC) without re-replacement. These two treatment modalities were retrospectively assessed. Methods Retrospective clinical chart review was undertaken on 21 patients with prosthetic graft infection after thoracic aortic replacement between December 1999 and December 2012. Surgical outcomes were evaluated between the two groups: re-replacement group (group R, n = 14) and no-replacement group (group NR, n = 7). Results In-hospital survival rates were 64.3 % in group R and 85.7 % in group NR. Mortality in group R included five patients, sepsis in two patients, and intraoperative aortic rupture, heart failure, and cerebral infarction in one. Mortality in group NR included one patient (sepsis). In terms of long-term outcome, one patient in group R and one patient in group NR died of rupture of a residual aortic aneurysm, and one patient in group NR died of renal disease during follow-up (52.8 ± 41.5 months for R and 43.2 ± 28.5 months for NR; mean ± standard deviation). Conclusions Re-replacement of an infected prosthetic graft after a thoracic aortic operation still carries a significant risk for mortality. VAC therapy may provide an acceptable option for such a subgroup of patients with this serious condition.

Aspergillus fumigatus as a clinical entity is difficult to diagnose. We present a case, which could facilitate diagnosis and management of the aforementioned disease. A 60-year-old man with stent graft implantation in the descending aorta (6 years ago) presented with fever, night sweats, and weight loss over 5 months. Leukocytosis and elevated C-reactive protein were constantly spiking. Blood cultures were negative. Notably, the serum immunoglobulin E (IgE) level was strongly elevated (> 1,000 U/mL). Anamnestically, the patient suffered from a mild form of atopic dermatitis and bronchial asthma. The pulmonary status showed no abnormalities in the computed tomography image. Nonetheless, a chest scan revealed a suspected abscess around the stent graft of the descending aorta. Extra-anatomic ascending to descending aortic bypass (Gelsoft 22 mm, Vascutek, Juchinnan, Scotland, United Kingdom) was performed. Intraoperative samples revealed A. fumigatus. These findings were confirmed by polymerase chain reaction analysis. Infection by A. fumigatus represents a diagnostic challenge because blood cultures are usually negative, but expeditious treatment is required to prevent occurrence of irreversible complications. A late graft infection, possibly caused by A. fumigatus should be suspected in patients with implanted grafts, who suffer from unexplained, blood culture-negative fever that does not respond to antibiotics and who have a history of dermatitis or bronchial asthma with elevated IgE antibodies.

Purpose To investigate the process of bacterial invasion from the surface to inside prosthetic vascular grafts. Methods Elastomer-sealed Dacron vascular grafts (ESDVGs) and gelatin-coated Dacron vascular grafts (GCDVGs) were cut into 6-cm segments and placed in a U-shaped configuration on culture plates. Physiological saline was poured inside the grafts and a suspension of Pseudomonas aeruginosa was added to the outside. Samples taken from inside the grafts at nine time points for up to 60 h were spread on agar. Bacterial colonies were then analyzed. The grafts were also examined using scanning electron microscopy (SEM). Results Contaminated vascular graft models were produced in 18 ESDVGs (group T) and 12 GCDVGs (group G). The bacterial counts inside the vascular grafts in both groups increased over time. Bacterial colonies were confirmed in all samples from group G by 30 h, whereas bacteria appeared inside the grafts from group T at various times between 0 and 60 h. Bacteria were undetectable in one model from group T throughout the study. SEM revealed that the elastomeric membrane in the ESDVG was uneven. Conclusion Bacterial invasion of vascular grafts does not always occur immediately after contamination. ESDVGs may be more resistant to bacterial invasion as they have a thicker and evenly enriched elastomeric membrane.

Highlights • Infection of infrainguinal bypass is a challenging complication with a high risk rate mortality and limb loss. • Biosynthetic grafts are considered as the last chance to deal with bypass infection and if they fail other solutions are required. • Besides occlusion of biosynthetic grafts other complications may occur during the follow up such as infection and haemorrhage. • Recurrent infection of two different grafts used for infrainguinal bypass makes meaningless the use of other materials at the same surgical site. • Extra- anatomical bypass avoiding the compromised and complicated surgical site could be a solution to assure limb salvage and patient survival., Introduction Biosynthetic prosthesis has become the trend to carry out arterial reconstruction in infected sites since considered to be resistant to infection. Late graft occlusion is the only complication reported in literature so far. We report a case of biosynthetic graft infection which led to early detachment of the femoral anastomosis of a femoral-popliteal above-knee bypass. Material A 76-year-old man developed groin infection 3 months later after performing an ePTFE femoral-popliteal above-knee bypass for critical limb ischemia. He was re-admitted for groin infection involving the vascular structures. Explantation of the existing bypass and its replacement with a biosynthetic graft (omniflow II) was performed. Detachment of the proximal anastomosis occurred 6 days later leading to groin haematoma. Consequently, retroperitoneal access was performed for clamping the external iliac artery so as to control haemorrhage followed by explantation of the biosynthetic graft. An external iliac-popliteal above-knee bypass was tailored in order to save the limb and it was performed using a transobturator approach avoiding the infected site. In both cases bacterial cultures resulted positive for Morganella Morganii. The groin wound was treated separately with negative pressure medication healing definitively within 20 days and after 3-month follow-up the bypass was still patent. Conclusion This is the first report of biosynthetic graft infection used for infrainguinal reconstruction leading to haemorrhage due to anastomosis disrupture. Using an extra-anatomical access for providing blood inflow to the leg avoiding the infected site and treating safely the groin wound with VAC therapy revealed to be a valid approach.

Currently available conduits for in situ reconstruction after excision of infected aortic grafts have significant limitations. The Omniflow II vascular prosthesis is a biosynthetic graft associated with a low incidence of infection that has succesfully been used in the treatment of infected infrainguinal bypass. We report on the first use of the Omniflow II prosthesis for in situ reconstruction after aortic graft infection. A bifurcated biosynthetic bypass was created by spatulating and anastomosing two 8-mm tubular Omniflow II grafts. This bypass was used for in situ reconstruction after excision of infected aortic grafts in three cases. After a mean follow-up of 2.2 years, no occlusion, degeneration, or rupture of the Omniflow II grafts was observed. Although one patient suffered from graft reinfection, the bypass retained structural integrity and no anastomotic dehiscence was observed. Treatment of aortic graft infection by in situ reconstruction with the Omniflow II vascular prosthesis is feasible. Its resistance to infection and off-the-shelf availability make this graft a promising conduit for aortoiliac reconstruction.

Background. Nuclear medicine imaging differs from other imaging modalities by showing physiological processes instead of anatomical details. Objective. To describe the current applications of positron emission tomography (PET) and single photon emission computed tomography (SPECT) as a diagnostic tool for vascular disease as relevant to vascular surgeons. Methods. A literature search identified articles focussing on vascular disease and PET or SPECT using the Pubmed database. Manual cross referencing was also performed. Results. PET and SPECT may be used to assess plaque vulnerability, biology of aneurysm progression, prosthetic graft infection, and vasculitis. The ability to combine computerized tomography scanning or magnetic resonance imaging with PET or SPECT adds detailed anatomical information and enhances the potential of nuclear medicine imaging in the investigation of vascular disease. Discussion. Considerable further information will be needed to define whether and where PET or SPECT will fit in a clinical strategy. The necessary validation studies represent an exciting challenge for the future but also may require the development of interdisciplinary imaging groups to integrate expertise and optimize nuclear diagnostic potential. (C) 2007 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Background: In this report we describe the in vivo antibacterial activity of linezolid in an experimental graft infection model in rats and compare it with teicoplanin. The objective of this study was also to determine the effects of the interaction of linezolid when it was combined with rifampicin and test this effect against strains of methicillin-resistant Staphylococcus aureus and Staphylococcus epidermidis. Materials and methods: Graft infections were established in the subcutaneous tissue of 130 Wistar rats by implantation of Dacron grafts followed by a topical inoculation with 2 × 107 CFU of clinical isolates of MRSA and MRSE. The study included a control group and six groups for each of the staphylococcal strains: an inoculated group that did not receive any antibiotic prophylaxis, two inoculated groups that received intraperitoneal prophylaxis with teicoplanin or linezolid alone, an inoculated group that received rifampicin-soaked grafts, and two inoculated groups that received a combination prophylaxis consisting of intraperitoneal teicoplanin or linezolid and rifampicin-soaked grafts. Results: There was a reduction in the quantitative bacterial graft cultures in all prophylaxis groups when compared with inoculated control groups. There was not a statistically significant difference between linezolid and teicoplanin prophylaxis groups. The best results were obtained by a combination of rifampicin-soaked grafts with linezolid or teicoplanin. Conclusions: We found no evidence to suggest that linezolid differs from teicoplanin regarding effectiveness in the prevention of prosthetic vascular graft infection. Linezolid plus rifampicin and teicoplanin plus rifampicin are demonstrated to be valuable prophylactic regimens. © 2007 Elsevier Inc. All rights reserved.

Background Vascular graft infections are infrequent complications with important morbidity and mortality rates. Pasteurella multocida, a Gram negative bacillus, is a normal oral commensal of many animals. For mankind, it is a pathogenous bacillus which is rarely implicated in vascular grafts. Case report We report hereafter the fourth case introduced in the international literature about vascular graft infections caused by P. multocida. The patient was successfully treated with a combination of a surgical graft change and a 6 weeks bi-antibiotic therapy. Discussion There is fours case reported in litterature with quite different antibiotic drugs and duration. Conclusion P. multicoda graft infection should be long with initial intravenous drug and mainteance traitement should not be required.

Key Clinical Message Explantation of an infected patent vascular graft does not necessarily require concomitant revascularization procedures. The need for revascularization can be determined by a trial cross‐clamping of the graft and clinical assessment of limb perfusion. We report a case of an infected axillofemoral graft transgressing the chest wall in a surgically high risk patient.

Objectives To evaluate the ability of the retroperitoneum to serve as a barrier, against bacterial contamination, between the peritoneal cavity to the retroperitoneal space. Methods Seventy rats had a small piece of knitted Dacron graft placed in the retroperitoneal space and 106–109 colony forming unit (cfu) Enterococcus faecalis was injected into the peritoneal cavity. In half the retroperitoneal (RP) group, the retroperitoneum was preserved and in the remainder, the open peritoneal (OP) group, needle holes were created. Grafts were harvested after 1, 4, or 7 days and cultured for E. faecalis. A blood sample was collected from three rats in each group for culture before the graft was harvested. Results Graft infection did not develop in any rat injected with 106 or 107 cfu in the RP group, while seven out of the 10 graft cultures of the OP group grew E. faecalis (P=0.003). In rats injected with 108 or 109 cfu, five out of the 10 graft cultures in the RP group and eight out of 10 in the OP group grew E. faecalis. All blood cultures were negative when the injected bacterial count was 107 cfu or less. One out of the three blood cultures was positive at 108 cfu, and all were positive at 109 cfu. Conclusions These results suggest that an intact retroperitroneum acts as a protective barrier against intraperitoneal bacterial contamination, particularly when blood cultures are negative.

We present the case of a 62-year-old man who presented with a methicillin-resistant Staphlococus aureus carotid patch infection. He was treated successfully by carotid patch explantation and revision saphenous vein-patch angioplasty to his carotid artery. This case suggests successful outcomes can be obtained with early revision surgery in this rare but potentially fatal post-operative infection.

A 63-year-old male underwent emergency repair of a ruptured juxtarenal aortic aneurysm via a transabdominal approach using an aorto-bi-iliac Dacron graft. This became infected. A right axillobifemoral bypass was placed and the infected graft was removed with oversewing of the aorta. The patient was re-admitted 8 months later with an infected axillobifemoral prosthesis. We harvested both femoral veins (FV) and spliced them to perform a left thoracobifemoral bypass with simultaneous explantation of the infected graft. The patient remains well with a patent graft 20 months post-operatively.

WHAT THIS PAPER ADDS This study introduces a new visual grading score that improves the accuracy of FDG-PET/CT in the detection of prosthetic vascular graft infections (PVGIs). This will not only improve and speed up the diagnosis of PVGI but also allow for the monitoring of medical and surgical therapy thereof. Morbidity, mortality, and costs of treatment may significantly decrease in the near future because of the enhanced diagnostic accuracy and improved therapeutic management. Objective: The aim of this study was to evaluate the diagnostic accuracy of positron emission tomography/ computed tomography with 18 F-fludeoxyglucose (FDG-PET/CT) in a population with suspected graft infection and to validate a new diagnostic imaging score for FDG-PET/CT. Methods: This was a prospective cohort study. FDG-PET/CT was performed prospectively in 34 patients with suspected graft infection, in 12 of them before the start of antimicrobial treatment. Diagnostic accuracy was assessed using a new five point visual grading score and by using a binary score. Maximum standardized uptake values (SUVmax) were calculated for quantitative measurements of metabolic activity, and cut off points were calculated using the receiver operator curve (ROC). The standard of reference was a microbiological culture, obtained after open biopsy or graft explantation. Results: Using the new scale, FDG-PET/CT correctly recognized 27 patients with graft infection, one patient was diagnosed as false positive, six patients were correctly classified as true negative, and no patients were rated false negative. Hence, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of FDG-PET/CT for the diagnosis of graft infections were 100%, 86%, 96%, 100%, and 97%, respectively. Using a previously established binary score, sensitivity, specificity, PPV, NPV, and accuracy were 96%, 86%, 96%, 86%, and 94% respectively. ROC analysis suggested an SUVmax cut off value of � 3.8 to differentiate between infected and non-infected grafts (p < .001). Additionally, FDG-PET/CT provided a conclusive clinical diagnosis in six of seven patients without graft infection (i.e., other sites of infections). Conclusions: The diagnostic accuracy of FDG-PET/CT in the detection of aortic graft infection is high. A newly introduced five point visual grading score and early imaging prior to antimicrobial treatment may further improve the diagnostic accuracy.

Objectives: to investigate the prevalence of MRSA infection in patients treated in a major vascular unit and examine its consequences. Design and Methods: a retrospective case-note review was performed. Results: during the period 1993 to 2000, a total of 172 patients (4.4% of total) were positive for MRSA. Of these 97 were colonised and 75 were infected by MRSA. The proportion of wound or graft infections caused by MRSA has increased (4% in 1994 to 63% in 2000). Three patients developed native artery infection (one following aortic stent insertion and 2 following embolectomy). All patients with aortic graft infection died. All patients with infected prosthetic infrainguinal bypass ended up with an amputation. Conclusion: the prevalence of MRSA infection is increasing. Infection of aortic grafts appears to be uniformly fatal and lower limb graft infection is associated with high limb loss.

Introduction and lumbar pain radiating to the right groin. Five years previously he had undergone surgery elsewhere An aortic graft infection is among the most serious for Leriche syndrome and received an aortobifemoral complications of surgical arterial reconstruction, with bypass with a 14×7 Dacron bifurcation graft. No an incidence of 0.4–2.6%, it carries with it significant complications or infections of note arose immediately mortality and morbidity. Aortic graft infections can be or over the ensuing years. caused by many different pathogens. Cultures from On admission to this hospital the patient had a high early graft infections most commonly yield coagulasefever, an increased erythrocyte sedimentation rate and negative Staphylococcus aureus; those from late ina leukocytosis. Physical examination disclosed a painfections more often grow Staphylococcus epidermidis. less, pulsatile mass in the mesogastric region. PeriOther bacteria frequently responsible for graft inpheral pulses were present and groin examination fections are Pseudomonas aeruginosa, Escherichia coli and raised no suspicion of septic complications. Abdominal the Klebsiella species, found in 20% of all cases. The ultrasound scanning suggested the presence of a small Salmonella species – relatively frequent in arteritis and pseudoaneurysm with no evident perigraft fluid colaneurysmal infections – only occasionally cause graft lections, and a small stone in the right ureter. On the infections. In a review including 150 cases of thoracic day after admission, a sudden episode of hypotension or abdominal aortic infections caused by the various developed, with intense lumbar pain. An abdominal Salmonella species over the years 1948 to 1999, the angiographic CT scan disclosed a ruptured pseudomost frequent causative organisms were Salmonella aneurysm involving the proximal anastomosis (Fig. typhimurium and Salmonella enteridis. 1). The patient was therefore referred to the vascular In contrast to primary infections of the large arteries, surgery unit. only a few cases of aortofemoral graft infections due At emergency laparotomy, the right side of the to Salmonella have been described to date. proximal anastomosis appeared to have become detached and the graft was surrounded by pus. The Case Report common body of the graft measured 30 mm in diameter. The right and left graft branches appeared A 62-year-old man was admitted to the Department well incorporated and uninfected as did the femoral of General Surgery for the investigation of pyrexia anastomoses. After clamping of the infrarenal aorta the infected prosthetic graft was entirely removed, the ∗ Please address all correspondence to: M. Taurino, Department of aortic stump was ligated and a right axillobifemoral Surgery, ‘‘Paride Stefanini’’, 1st Chair of Vascular Surgery, University of Rome ‘‘La Sapienza’’, viale del Policlinico 155, 0016 Rome, Italy. bypass was constructed. The postoperative course was

Objective The aim of the present study was to analyze our results of treating synthetic vascular graft infection in the aorto-femoral segment with venous allografts. Patients and methods During 1997–2006 we treated 11 male patients with venous allografts for aorto-femoral segment prosthetic graft infection. Patients were followed postoperatively with patency assessment based on Doppler ultrasonography. Results The mean interval between the implantation of the synthetic vascular graft and the appearance of infection was 43 ± 29 months (range 5 months–10 years). Overall primary patency of the venous allograft was 100%, 88% and 66% at 1, 6 and 36 months, respectively. Secondary patency rates of the venous allograft were 94% and 73% after 5 and 8 years, respectively. Overall survival rate was 100%, 64%, 46% and 27% after one month, 3, 5 and 8 years, respectively. Limb salvage rate was 100%, 94% and 73% after 1 month, 5 and 8 years, respectively. Conclusions The use of in situ venous allograft for the treatment of synthetic graft infection in the aorto-femoral segment has led to favourable short- and long-term results.

Background. During the last decade endovascular therapy has been established as an alternative treatment for a variety of vascular diseases. Neither the classic operating room (OR), nor the conventional angiography suite is optimal for both open surgery and endovascular procedures. Important issues include: quality of the imaging equipment, radiation burden, ease Of use of the equipment, need for specially trained personnel, ergonomics, ability to perform both open and percutaneous procedures, sterile environments, as well as quality and efficiency of patient care. Methods. A literature search identified articles pertinent to the key issues during the decision-making process of creating the optimal endovascular suite. Manual cross-referencing also was performed. Results and conclusion. The most important feature of working in a dedicated endovascular suite should be the ability to attain best treatment of vascular patients. Whether the interventional radiologist or the vascular surgeon uses the facilities is of less importance. A fixed fluoroscopy unit is preferred, above a portable C-arm. Establishment of an endovascular operating room suite has the benefit of a sterile environment, the possibility of performing hybrid procedures and conversions when necessary. Moreover, angiography immediately before treatment gives contemporary anatomical information, and after treatment provides quality control. As a consequence, better quality and service can be provided to the individual patient. (c) 2007 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Background: Graft infections are severe complications of vascular surgery that may result in amputation or mortality. Staphylococci are the most frequent cause of vascular graft infections. Objective: In this study we assessed the prophylactic efficacy of linezolid in comparison with vancomycin in preventing prosthetic vascular graft infection due to methicillin-resistant Staphylococcus aureus (MRSA) or methicillin-resistant Staphylococcus epidermidis (MRSE). Methods: This randomized, controlled, experimental study using healthy adult (aged >5 months) male Wistar rats was conducted in the research laboratory of the Pamukkale University, Denizli, Turkey. The study consisted of an uncontaminated control group and 3 groups for both staphylococcal strains: a contaminated group that did not receive any antibiotic prophylaxis; a contaminated group that received preoperative intraperitoneal (IP) prophylaxis with vancomycin; and a contaminated group that received preoperative IP prophylaxis with linezolid. All rats received a vascular Dacron graft placed inside a subcutaneous pocket created on the right side of the median line. Sterile saline solution (1 mL), to which MRSA or MRSE at a concentration of 2 × 107 colony-forming units per milliliter had been added, was inoculated onto the graft surface using a tuberculin syringe to fill the pocket. The grafts were explanted 7 days after implantation and assessed by quantitative culture. Results: Seventy rats (mean [SD]weight, 323.7 [17.9]g; mean [SD]age, 5.98 [0.64] months) were evenly divided between the 7 groups. Statistical analysis of the quantitative graft culture suggested that both vancomycin and linezolid were effective in significantly inhibiting bacterial growth when compared with the untreated contaminated groups (all, P < 0.001). However, a statistically significant difference was not observed between the bacteria count in the vancomycin and linezolid prophylaxis groups. When a comparison was made between the bacterial growth in the contaminated control groups, MRSA had significantly greater affinity to the Dacron prostheses than MRSE (all, P < 0.001). Conclusion: Our study found that linezolid was as effective as vancomycin in suppressing colony counts in MRSA- or MRSE-infected vascular Dacron grafts in rats. © 2007 Excerpta Medica, Inc.

Vascular prosthetic graft infection is a major complication of vascular surgery that starts with adhesion of the microorganism to the graft. Because slime-forming microorganisms are the major causative agents in graft infection, the goals of investigators in this study were (1) to investigate the bacterial adherence of slime-forming and non-slime-forming coagulase-negative staphylococci (CNS), and (2) to determine the role of neuraminidase (NANase) in bacterial adherence to the biosynthetic ovine collagen graft. Human plasma was instilled and incubated at 37°C in preparation for fibrin deposition of grafts. After 48 hours, incubation grafts were drained and inoculated with slime-forming and non-slime-forming CNS in tryptic soy broth in the presence and in the absence of neuraminidase. After 24 hours of incubation at 36°C, grafts were vortexed and cultured for colony count. Bacterial counts were expressed as total colony-forming units per longitudinal centimeter of the graft. Slime-forming CNS had greater affinity to the collagen graft compared with non-slime-forming CNS (P.05). Results show that slime plays an important role in the pathogenesis of vascular graft infection. Adherence of slime-forming CNS can be decreased through the administration of NANase. This may have implications for the development of neuraminidase-embedded vascular grafts designed to reduce the occurrence of biomaterial-related infection. ©2006 Health Communications Inc.

Background The aim of the study was to investigate the in vivo efficacy of local and systemic antibiotic prophylaxis in the prevention of Staphylococcus (S.) epidermidis graft infection in a rat model and to evaluate the bacterial adherence to frequently used prosthetic graft materials. Methods Graft infections were established in the subcutaneous tissue of 120 male Wistar rats by implantation of Dacron/ePTFE grafts followed by topical inoculation with 2 × 107 CFUs of clinical isolate of methicillin-resistant S. epidermidis. Each of the graft series included a control group, one contaminated group that did not receive any antibiotic prophylaxis, two contaminated groups that received systemic prophylaxis with teicoplanin or levofloxacin and two contaminated groups that received teicoplanin-soaked or levofloxacin-soaked grafts. The grafts were removed 7 days after implantation and evaluated by quantitative culture. Results There was significant bacterial growth inhibition in the groups given systemic or local prophylaxis (P < 0.05). Methicillin-resistant S. epidermidis had greater affinity to Dacron graft when compared with ePTFE graft in the untreated contaminated groups (P < 0.05). Conclusion The study demonstrated that the usage of systemic or local prophylaxis and preference of ePTFE graft can be useful in reducing the risk of vascular graft infections caused by staphylococcal strains with high levels of resistance.

Objective. To investigate the prophylactic efficacy of systemic, topical, or combined antibiotic usage in the prevention of late prosthetic vascular graft infection caused by methicillin-resistant Staphylococcus epidermidis (MRSE) and the differential adherence of S. epidermidis to Dacron and ePTFE grafts in a rat model. Materials and methods. Graft infections were established in the back subcutaneous tissue of 120 adult male Wistar rats by implantation of 1-cm 2 Dacron/ePTFE prosthesis followed by topical inoculation with 2 × 107 CFU of clinical isolate of MRSE. Each of the series included one group with no graft contamination and no antibiotic prophylaxis (uncontaminated control), one contaminated group that did not receive any antibiotic prophylaxis (untreated control), one contaminated group in which perioperative intraperitoneal prophylaxis with vancomycin (10 mg/kg) was administered, two contaminated groups that received rifampicin-soaked (5 mg/1 ml) or vancomycin-soaked (1 mg/1 ml) grafts, and one contaminated group that received a combination of rifampicin-soaked (5 mg/1 ml) graft with perioperative intraperitoneal vancomycin prophylaxis (10 mg/kg). The grafts were removed sterilely 7 days after implantation and evaluated by using sonication and quantitative blood agar culture. Results. MRSE had significantly greater adherence to Dacron than ePTFE grafts in the untreated contaminated groups (P < 0.001). Rifampicin had better efficacy than vancomycin in topical application, but the difference was not statistically significant (P > 0.05). Intraperitoneal vancomycin showed a significantly higher efficacy than topical vancomycin or rifampicin (P < 0.001). The best results were provided by a combination of intraperitoneal vancomycin in rifampicin-soaked graft groups (P < 0.001). Conclusions. The combination of rifampicin and intraperitoneal vancomycin seems to be the best choice for the prophylaxis of late prosthetic vascular graft infections caused by MRSE. © 2005 Elsevier Inc. All rights reserved.

ObjectivesThe purpose of this study was to assess short- and mid-term results of in-situ revascularisation (ISR) using silver-coated Dacron prostheses and bowel repair for management of secondary aorto-enteric fistulae (SAEF).DesignSingle-centre retrospective chart review.Material and methodsThis study includes all the patients treated by ISR using silver-coated Dacron for SAEF between 2006 and 2010. Primary end points were mortality and survival rates. Secondary end points were reinfection-free survival and secondary patency rates.ResultsEighteen male patients with SAEF with a median age of 64 years were operated by ISR using silver-coated Dacron during the study period without operative death. The 30-day mortality was 22% and the in-hospital mortality rate was 39%. Indeed, during hospitalisation, a duodenal leak was observed in four patients including three who died. Four others patients died due to multi-system organ failure. Median follow-up was 16 months (range 1–66). The survival rate at 12 months was 55%. One duodenal leak was observed leading to death. The reinfection-free survival and the secondary patency rates at 12 months were 60% and 89%, respectively.ConclusionIn-situ revascularisation with silver-coated Dacron provides acceptable results in terms of mortality. This treatment may be useful for simple vascular reconstruction and allow greater attention to bowel repair that is a determinant in short- and mid-term survival.

The cornea has a mechanism of protecting itself against bacterial, viral, or fungal infections, but this mechanism often weakens after penetrating keratoplasty (PKP) procedures. Moreover, other factors, such as long-term use of topical corticosteroid and soft contact lens, graft hypoesthesia, suture-related problems, and ocular surface disorders, including dry eye, make the cornea more vulnerable to infection [1,2,3,4,5]. The incidence of graft infection following PKP varies from 1.76% to 12.1% [1,2,3,4,5,6,7]. Despite improvement in antibiotic treatment, the treatment failure of microbial keratitis remains an important problem. The rate of treatment failure is estimated to be around 10% [8,9], but it is significantly higher in eyes that underwent PKP, ranging from 26% to 57%, [5,6,7]. Some studies have reported that long-term prophylactic antibiotic administration is a risk factor for the emergence of antibiotic-resistant flora, and this may be related to the poor treatment outcome of graft infection [10,11]. Graft infection is a serious complication of PKP and can lead to poor visual outcomes. Hence, knowing the factors that affect treatment outcome can improve patient prognosis. Although several studies have evaluated the risk factors of graft infection, to the best of our knowledge, there have been no reports on the prognostic factors affecting treatment outcome [1,2,3,4,5]. Therefore, we performed a comparative study between "treatment success" and "treatment failure" groups among patients who showed graft infection following PKP and investigated the factors associated with poor treatment outcome.

Objective: To develop an infection-resistant polytetrafluoroethylene (PTFE) vascular graft for potential clinical use in grafting in sites of bacterial contamination and in replacement of the infected grafts. Setting: Experimental study in rabbits Materials and methods: An antibiotic ofloxacin (OFLX) was bonded to a sheet of PTFE by impregnation, which was cut and twisted into fine threads. The in-vitro antibacterial activity of OFLX-PTFE thread was determined by measuring the zone of growth inhibition against Escherichia coli . The thread was spirally coiled around a ridged outerwall PTFE to make the OFLX-PTFE graft. OFLX-PTFE graft or control graft was interposed in the inferior vena cava (IVC) of rabbits and the entire graft was covered with fibrin containing a fixed number of E. coli . Three or 7 days after the grafting, the grafts with perigraft tissue were harvested and subjected to bacteriological studies. Results: In spite of early phase rapid elution of OFLX, a significant antibacterial activity was retained for more than 2 weeks. The antibacterial activity of OFLX-PTFE threads implanted in the subcutaneous space of rabbits decreased to 48% after 24 h and to approximately 1% after a week. The swab culture of all the control grafts was positive, while only one of 13 PTFE-OFLX grafts was positive. The number of viable bacteria in the perigraft tissue of OFLX-PTFE grafts was remarkably low in comparison with that of control grafts. Thus, the OFLX-PTFE grafts exhibited a marked in-vivo antibacterial activity. Conclusion: By a unique method, it was possible to furnish PTFE graft with an excellent infection-resistant property, without affecting the original biological behaviour.

Abdominal aortic aneurysms can either be treated using open methods or endovascular stent grafts. Nevertheless, until the UK EVAR randomised controlled trials report, we do not know which, if either, of these two methodologies is preferable for the treatment of these patients. Endovascular aneurysm repair can produce acceptable rates of peri-operative morbidity and mortality, but appears to require an increased level of intervention during the follow-up period. Such intervention is primarily targeted at the treatment of endo-leaks, limb occlusion and device disintegration. Stent graft infection is a rare occurrence.

The authors review their experience with 318 direct radiocephalic arteriovenous fistulas created for chronic maintenance hemodialysis over the past six years. Thirty-five of the fistulas (11 %) never functioned or thrombosed within the first month. The early failure rate was significantly different between groups older and younger than fifty years of age (p < 0.05). Moreover, the early thrombosis rate was related to the suture techniques used: 8.62% for the interrupted suture group and 20.63% for the running suture group (p < 0.05). Average patency duration for still functioning fistulas in 120 patients is 38.8 months; for the 58 patients who had late failure it was 14.9 months.

A 58-year-old man was admitted to the hospital with long-term relapsing fevers, malaise, weight loss, and inflammatory laboratory abnormalities. His medical history revealed abdominal aortic aneurysm repair with a bifurcated prosthetic graft 6 months before presentation. An extensive diagnostic workup, including transesophageal echocardiography, thoracic and abdominal computed tomography (CT) scans (A), and Tc leucocyte scanning, showed no abnormalities—in particular, no signs of endocarditis or graft infection. Because serology for chronic Q fever was positive (anti–Coxiella burnetii immunoglobulin G phase I, 1:10,000), targeted antibiotic therapy was started, without clinical response. Subsequent fluorine 18–fluorodeoxyglucose positron emission tomography (FDG-PET) scanning showed an area of increased intensity is the abdomen. FDG accumulates in organ tissues with a high rate of glycolysis. Besides neoplastic cells, lesions with a high concentration of activated inflammatory cells show increased uptake of FDG. Fusion of PET and CT images located the increased uptake in the vascular graft, suggesting infection of the prosthetic graft (cover image and B). The graft was removed, a neoaortoiliac system was created with autologous veins, and antibiotics were given. Coxiella burnetii polymerase chain reaction and culture of the removed graft remained negative (D. Raoult, Unite des Rickettsies, Marseille). The sensitivity of these diagnostic tests, however, is low, whereas an anti–C burnetii immunoglobulin G phase I titer of 1:1600 or more has a sensitivity for chronic Q fever of 100%. After surgery, the patient recovered completely. An FDG-PET/CT scan 9 months later was normal (C). Antibiotic treatment will be continued for at least 3 years. Second to cardiac valves, vascular grafts are the most frequent site of chronic Q fever. Treatment consists of a combination of surgical removal of the infected graft and prolonged antibiotic therapy. Despite these measures, mortality remains high. 1 By combining functional and morphologic information, PET/CT fusion images result in a higher diagnostic accuracy than the separate imaging modalities. 2 Therefore, FDGPET/CT scanning can be a promising tool for identification of occult infectious foci, especially in culture-negative infected cardiovascular devices such as Coxiella burnetii-infected vascular grafts, as this case demonstrates.

During the last fifteen years, we performed a total of 855 aortofemoral re constructions. Fifteen (1.75%) grafts were surgically removed (completely or partially) owing to a severe infection (Szilagyi: Grade 3) at a mean of 66.3 months (SD ± 37.9) after their implantation. Diagnosis was always clinically evident. In 10 patients, the graft was partially removed (one or two limbs). In 3 of the 10, graft infection progressed requiring complete graft removal after a mean of 18.6 days. In the other 5 patients, the graft was removed "in toto" at the time of the first operation. In 9 cases, revascularization was accomplished by means of a "remote" takeoff reconstruction (thoracic aorta or axillary ar tery), whereas in 8 cases (3 recurred) reconstruction was performed with a "local" takeoff reconstruction (stump or aortoiliofemoral arteries). One patient was not revascularized, because the limb was already amputated. Recurrence of infection was higher in the patients treated by partial removal of the graft (p < 0.05), even though the stump sterility was always evaluated by means of intraoperative culture. The mortality of patients with recurrence of infection was 66.6%. Multiple operations of the femoral site were considered a factor in causing aortofemoral graft infection (p < 0.01). Diabetes was not considered a factor in causing infection (p n.s.). Grafts with remote takeoff reconstruction have better long-term results in terms of limb salvage and survival when compared with local takeoff recon struction (p < 0.05).

Objective To assess the outcome of vacuum-assisted wound closure (VAC ® ) therapy for infected bypass grafts. Methods A retrospective 7-year review of patient records from 2004 to 2011 of all patients receiving VAC ® therapy for infected bypass grafts. Results Thirty-seven patients with 42 wounds and 45 infected bypass (28 synthetic) grafts received VAC ® treatment. Two serious bleeding episodes from the suture lines occurred. The median VAC ® therapy time was 20 days. The proportion of patent bypass grafts was 91% (41/45) at a median time of 3.5 months from the start of VAC ® therapy. Five patients with seven bypasses had persistent infection or re-infection, and the total graft preservation rate was 76% (34/45). The median follow-up time was 15 months. The presence of two infected bypass grafts in one groin wound was associated with an increased major amputation rate (hazard ratio (HR) 7.4 [95% confidence interval (CI) 2.0–27.5]), and synthetic graft infection (HR 5.0 [95% CI 1.5–17.4]) and non-healed wound (HR 3.6 [95% CI 1.5–8.7]) were associated with mortality. Conclusion VAC ® therapy of infected bypass grafts was able to induce effective wound healing without compromising the early bypass function. Two infected synthetic bypasses in the wound were associated with the highest risk of adverse outcome.

Prosthetic graft infection in the ascending aorta or aortic arch is a life-threatening complication. Redo graft replacement is also associated with high mortality and morbidity rates. Conservative treatments without graft removal recently developed as alternatives to conventional surgical approach have been reported with successful outcomes. We report a case of successful treatment of prosthetic graft infection in the aortic arch, for which percutaneous catheter drainage was initially performed prior to open surgery, followed by graft coverage with an omental flap.