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Invited Commentary fromAudra A.Duncan MD, FACS, FRCSC
71
pneumonia developed and responded to antibiotics and incentive spirometry.
The patient was discharged on the 12th postoperative day. The explanted graft was well
incorporated at the iliac anastomosis and was
lined by pseudointima on the inside. However,
the external surface of the main body of the graft
did not show any incorporation.
Discussion
Endovascular repair of AAA is an important
technical advance in the management of patients
at high risk who are likely to have signicant
perioperative morbidity and mortality rates with
conventional aneurysm resection [1, 2]. However,
rupture of AAA following endovascular repair is
well-known [3–6]. Graft limb occlusion, aortoenteric stula, endograft infections, and paraplegia
have also been reported [7–10]. Since this was a
rst-generation endograft (AneuRx), there was
no suprarenal xation. In addition, there was signicant angulation of the aortic neck which
resulted in Type I endoleak and subsequent rupture. This patient did not come for follow-up, and
this is a signicant problem in patients who are
undergoing endovascular aneurysm repair
(EVAR). It is quite possible that if Type I endoleak
was detected and managed at that time, rupture of
the AAA may not have occurred. Repair of ruptured AAA in the presence of aortic endograft
can be technically demanding because proximal
control is more difcult to obtain and the removal
of the endograft may result in a weak and thinned
out aortic neck for proximal anastomosis. Most
authors have recommended supraceliac control
of the aorta. Proximal control is obtained above
the renal arteries after ligating the left renal vein
in this patient.
Endovascular repair for ruptured AAA in a
patient with prior EVAR can be undertaken in
patients with rupture due to Type III endoleak.
However, in patients with Type IA endoleak,
there may not be enough aortic neck length available for application for deployment of aortic cuff;
endovascular repair may not be the best option.
Author has treated placement of a Palmaz™ stent
(Cordis, Hialeah, FL) in a few patients with rupture due to Type IA endoleak, but these patients
require rigorous follow-up as they may need further intervention (fenestrated graft) to prevent
Type 1A endoleak from recurring.
Invited Commentary fromAudra
A.Duncan MD, FACS, FRCSC
In this patient with migrated, malpositioned
endograft 16 months after implantation, a very
rare complication of inferior vena cava laceration
from the penetration of the dislodged graft limb
occurred. Although this type of fairly rapid
migration and disconnection of graft limbs is
much less likely in current generation grafts, this
case addresses several key points. The rst concern is one of graft sizing. Because the patient
was considered to be a very high cardiac risk at
the time of original presentation, it is likely that
the surgeon justied placing a 28 graft in a 28
aortic neck despite the lack of necessary oversizing. In the year 2000, larger grafts were not available commercially, nor were fenestrated grafts
(even physician modied ones) used. However,
one could have considered performing a hybrid
renal debranching with a more proximally placed
endograft, 6 weeks after placement of a baremetal coronary stent. The second point that this
case demonstrates is if graft sizing is suboptimal,
very close follow-up should be emphasized and
documented.
Finally, the patient fortunately did well after
open repair despite his previously documented
comorbidities. However, the authors note the
placement of a supraceliac as a preferred form of
control. Although supraceliac control may be
necessitated by anatomy or rupture, in the case of
rupture, the clamp can be repositioned more distally once the infrarenal or juxtarenal anatomy is
dened. In the case of an AneuRx graft, the proximal aspect of the endograft is rarely incorporated into the aortic wall, and therefore the graft
can be removed through the open sac, and the
clamp replaced at the infrarenal aorta. Several
studies [11–13] have conrmed that supraceliac
clamp for repair of complex aortic disease is an
19 Rupture ofAbdominal Aortic Aneurysm withTear ofInferior Vena Cava inaPatient withPrior Endograft
72
independent risk factor for cardiac complications, and judicious use of a supraceliac clamp
results in improved cardiac outcomes. Therefore,
in this patient with known severe cardiac disease,
limiting or eliminating supraceliac clamp would
have been recommended, despite his ultimate
excellent outcome.
References
1. Bernhard VM, Mitchell RS, Matsumara JS, et al.
Ruptured abdominal aortic aneurysm after endovascular repair. J Vasc Surg. 2002;35:1155–62.
2. Fransen GAJ, Vallabhaneni SR, Van Marrewijk CJ,
et al. Rupture of infra-renal aortic aneurysm after
endovascular repair: a series from EUROSTAR registry. Eur J Vasc Endovasc Surg. 2003;26:487–93.
3. Tuma MA, Hans SS. Rupture of abdominal aortic
aneurysm with tear of inferior vena cava in a patient
with prior endograft. J Vasc Surg. 2002;35:798–800.
4. Cho JS, Park T, Kim JY, et al. Prior endovascular
abdominal aortic aneurysm provides no survival
benets when the aneurysm ruptures. J Vasc Surg.
2010;52:1127–34.
5. Harris PL, Vallabhaneni SR, Desgranges P, et al.
Incidence and risk factors of later rupture, conversion,
and death after endovascular repair of infrarenal aortic
aneurysms: the EUROSTAR experience. J Vasc Surg.
2000;32:739–49.
6. May J, White GH, Stephen MS, et al. Rupture of
abdominal aortic aneurysm: concurrent comparison
of outcome of those occurring after endovascular
repair versus those occurring without previous treatment in an 11-year single center experience. J Vasc
Surg. 2004;40:860–6.
7. Coppi G, Gennai S, Saitta G, etal. Treatment of ruptured abdominal aortic aneurysm after endovascular
abdominal aortic repair: a comparison with patients
without prior treatment. J Vasc Surg. 2009;49:582–8.
8. Mehta M, Paty PS, Roddy SP, etal. Treatment options
for delayed AAA rupture following endovascular
repair. J Vasc Surg. 2011;53:14–20.
9. Candell L, Tucker LY, Goodney P, etal. Early and
delayed rupture after endovascular abdominal aortic
aneurysm repair in a 10-year multicenter registry. J
Vasc Surg. 2014;60:1146–52.
10. Calanescu I, Long G, Bove P, Khoury M, Brown OW,
Rimar S, Rizk Y, Uzieblo H, Hans SS. Rupture of
abdominal aortic aneurysm in patients with and without antecedent endovascular repair. Ann Vasc Surg.
2017;39:99–104.
11. Jean-Claude JM, Reilly LM, Stoney RJ, Messina
LM. Pararenal aortic aneurysms (the future of open
aortic aneurysm repair). J Vasc Surg. 1999;29:902–12.
12. West CA, Noel AA, Bower TC, Cherry KJ Jr,
Gloviczki P, Sullivan TM, et al. Factors affecting
outcomes of open surgical repair of pararenal aortic aneurysms: a 10-year experience. J Vasc Surg.
2006;43:921–7.
13. Sarac TP, Clair DG, Hertzer NR, Greenberg RK, etal.
Contemporary results of juxtarenal aneurysm repair. J
Vasc Surg. 2002;36:1104–11.
Prosthetic Graft Infection
Following Open Repair
ofRuptured Abdominal Aortic
Aneurysm
20
Prosthetic graft infection following aortic surgery is one of the most serious complications
encountered in vascular surgery practice.
Uniformly, prosthetic graft has to be explanted,
and except in rare instances of patients with aortoiliac occlusive disease, revascularization is necessary in almost all patients [1–8]. The
revascularization with antibiotic-soaked in situ
grafts, use of cryopreserved allograft, and use of
supercial femoral/popliteal veins and axillofemoral graft reconstructions are options available to the surgeon depending upon the type of
extent of bacterial infection [2–8].
History
A 52-year-old male presented with ruptured
abdominal aortic aneurysm (AAA) in July 2006.
The patient had chronic obstructive pulmonary
disease (COPD), hypertension, and Type II diabetes mellitus. He underwent emergent repair of
ruptured AAA with an 18 × 9mm knitted Dacron
graft. Aorto-bifemoral graft reconstruction
became necessary as common iliac arteries and
external iliac arteries on both sides showed severe
calcic stenosis. The patient had simultaneous
reimplantation of the right lower pole accessory
renal artery into the Dacron graft. In the postoperative period, he developed adult respiratory distress syndrome which responded to steroid
administration and ventilatory support.
In January 2007, the patient presented with
fever, back pain, and positive blood culture
(Staphylococcus aureus methicillin-sensitive).
CT scan of the abdomen and WBC scan conrmed infected aortic graft. On January 24, 2007,
the patient underwent explantation of the aortobifemoral graft with reconstruction using cryopreserved aortoiliofemoral graft (CryoLife
Kennesaw, GA). Dacron graft was unincorporated and surrounded by gelatinous perigraft uid
positive for methicillin-sensitive Staphylococcus
aureus. The patient was discharged on IV vancomycin and oral rifampicin.
On February 12, 2007, the patient presented
with back pain, and CT scan of the abdomen
showed perforation of the right iliac portion of
the cryopreserved graft with active leakage of
bloodv into the retroperitoneal and right peritoneal spaces (Fig.20.1).
Procedure
The patient underwent emergent removal of
cryopreserved allograft (CAA) with ligation of
the infrarenal abdominal aorta just below the
origin of renal arteries reinforced with omental
pedicle ap. Saphenous vein patch graftings
were performed at the site of femoral anastomoses. The patient was re-prepped for secondstage bilateral axillary artery to mid upper
supercial femoral artery bypass graft with
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_20
73
74
Fig. 20.1 Showing perforation of cryopreserved vein graft
20 Prosthetic Graft Infection Following Open Repair ofRuptured Abdominal Aortic Aneurysm
Fig. 20.2 CTA with bilateral axillofemoral graft
8 mm INTERING PTFE graft (W.L. Gore,
Flagstaff, AZ). Culture of CAA graft grew
Staphylococcus epidermidis and Candida albicans. The patient was treated with daptomycin,
uconazole, and rifampicin. Follow-up MRA
showed infrarenal ligation of the aorta with patent bilateral axillofemoral graft with good bilateral renal artery perfusion (Fig. 20.2). The
patient experienced slight quadriceps muscle
weakness on both sides which improved with
physical therapy and was discharged on the 14th
postoperative day. Postoperative CTA showed
patent bilateral axillofemoral grafts with distal
anastomoses to proximal supercial femoral
arteries. The patient was seen in the outpatient
clinic 6 weeks later with large seromas in the
chest wall on both sides (Fig.20.3). Aspiration
revealed clear serous uid negative cultures.
Repeated aspirations resulted in signicant
decrease in the size of the seromas.
Procedure
Fig. 20.3 Showing seromas surrounding bilateral axillo-
femoral graft
The patient presented on May 6, 2010, with
acute ischemia of right lower extremity secondary to thrombosis of the right axillofemoral
bypass graft. The patient underwent thrombectomy with reestablishment of satisfactory arterial ow to the right lower extremity. At the
same time, completion arteriogram of the axillofemoral graft using 4-French 100-cm-long
Omniush near the proximal anastomosis and a
completion right arteriogram with runoff study
were obtained. In the postoperative period, a
right upper thigh seroma was evacuated and a
sartorius muscle ap reconstruction was performed over the graft with application of a
wound vac. The patient was discharged on oral
warfarin. He developed recurrent thrombosis of
the right axillofemoral graft 3 months later and
underwent another thrombectomy. Due to recurrent thrombosis of the axillofemoral graft
despite anticoagulation, the patient underwent
redo aorto-bifemoral graft (PTFE WL Gore 16 ×
8mm) on May 6, 2011, via left retroperitoneal
approach. Insertion of bilateral ureteral stents
was performed by urology preoperatively. Left
11th intercostal space incision was made in the
left ank extending from posterior axillary line
to the lateral edge of the left rectus sheath. The
retroperitoneal plane was developed behind the
left kidney and tail of the pancreas and spleen,
and the peritoneal sac was rotated medially. The
stump of the infrarenal aorta was identied. The
left crus of the diaphragm was divided for a
short distance, and the lumbar branch of the left
75
renal vein was ligated and divided. Both renal
arteries were identied, and left iliac artery
stump was aborted because of excessive scarring in the area. Following systemic heparinization, the aorta was clamped above both renal
arteries. Proximal aortic anastomosis of the 16 ×
8 mm bifurcated PTFE graft was performed
using continuous 3-0 cardiovascular polypropylene suture. Suprarenal clamp time was
27minutes. The right limb of the graft was too
short to pass through the tunnel created in the
space of Retzius from the left lower quadrant to
the right groin. Therefore, the right limb of the
graft was extended by anastomosing 8 mm
externally supported right graft, so that anastomosis between the two grafts was in the left
ank. The graft was brought into the right groin,
and anastomosis was performed to the proximal
right supercial femoral artery over the vein
patch which had been performed at the time of
axillofemoral reconstruction. Femoral anastomosis was done on the left side to the proximal
supercial femoral and distal common femoral
artery after performing local endarterectomy of
the profunda femoris artery into the circumex
branches. A 5-0 cardiovascular polypropylene
suture was used for distal anastomosis. Both
femoral limbs of the axillofemoral graft were
ligated a few centimeters above the femoral
anastomosis.
The patient presented to the hospital on April
6, 2014, with acute ischemia of the right lower
extremity. CTA showed lling (embolus) in the
right popliteal artery and proximal posterior tibial artery probably from the residual nonfunctioning axillofemoral bypass graft (a small
cul-de-sac). The patient underwent right popliteal/tibial thromboembolectomy and takedown of
the right axillary to supercial femoral artery
bypass graft as well as takedown of the distal
anastomosis of the left axillary to supercial
femoral artery bypass. Completion arteriogram
showed satisfactory results. The patient presented
again to the hospital on June 6, 2014, with cool
right upper extremity. Axillary artery thrombectomy and ligation of the right axillofemoral
bypass was performed on June 6, 2014; similar
procedures were performed prophylactically on
the left side to prevent embolization. The patient
76
Fig. 20.4 Postoperative CTA showing patent in-line left
aortofemoral and crossover femoral-femoral graft
20 Prosthetic Graft Infection Following Open Repair ofRuptured Abdominal Aortic Aneurysm
was last seen in June of 2014 with no evidence of
recurrent graft infection with normal ankle brachial indices of both lower extremities. A follow up CT scan following aortofemoral reconstruction
showed patent graft (Fig.20.4).
Discussion
Incidence of prosthetic aortic graft infections has
been reported to be 0.6–3% [4]. Management
options in patients with aortic graft infection
include explantation of the graft and extraanatomic bypass placement (axillofemoral, in
situ rifampicin-bonded prosthetic graft, cryopreserved aortic allograft) [2–8]. In situ autogenous
aortoiliac/femoral reconstruction using supercial femoral and popliteal veins has been championed by Clagett etal. for prosthetic graft infection
[5]. Spiral vein graft constructed from the greater
saphenous vein has also been used for autogenous replacement of infected aortic prosthesis;
however, construction of spiral vein graft is timeconsuming [9]. Selection of revascularization
strategy depends on the type of bacterial ora
causing graft infection, extent of infection, and
presence or absence of aortoenteric stula.
Recently, Charlton-Ouw et al. reported 28
patients with infected infrarenal abdominal aortic
graft within situ reconstruction in 79% of
patients. Prosthetic graft, cadaveric homograft,
and native femoropopliteal were used with inhospital motility of 7% with reinfection rate of
25% [4]. The overall limb salvage and survival at
a mean follow-up of 2 and 5years was 82 and
46%, respectively [4]. Chung and Clagett
reported perioperative motility of 10% and 5-year
motility of 50% using autogenous veins [5].
Oderich et al. reported better patency using
reconstruction with rifampicin-soaked graft as
compared to axillofemoral graft reconstruction at
5 years (89% versus 48% p = 0.1). However,
there was similar incidence of graft reinfection
(11% for in situ replacement and 17% for axillofemoral graft) [8].
In this patient following rupture of the cryopreserved vein graft for aortic graft infection,
axillofemoral graft reconstruction was performed; however, the patient developed bilateral
seromas which did respond to repeated aspirations. As the patient developed recurrent axillograft occlusion in spite of anticoagulation, it
was decided to perform in-line aortofemoral
reconstruction via retroperitoneal approach.
However, the patient developed right upper
extremity and right lower extremity emboli secondary to thrombosis in the rst few centimeters
of axillary and femoral portion of the axillofemoral graft. Therefore, prophylactic ligation of
the left axillofemoral graft very close to the origin of the proximal anastomosis and very close
to the insertion at the distal anastomosis was
performed to prevent recurrent episode on the
left side. This report illustrates that aortic graft
infection carries signicant morbidity and that
late follow-up is necessary as reinfection rate is
high. It appears from the recent literature that
there is a trend toward in situ replacement either
with rifampicin- soaked prosthetic graft wrapped
with omentum or autogenous replacement of the
aortoiliac segment with autologous femoral
popliteal veins in preference to axillofemoral
graft reconstruction following removal of
infected aortic prosthetic graft.
References
77
Invited Commentary fromAudra
A.Duncan MD, FACS, FRCSC
This complex case showcases the ongoing struggle of managing aortic prosthetic graft infections
and why prevention is so important. The patient
was initially treated with open repair of a ruptured aneurysm requiring aorto-bifemoral bypass
based on severe concomitant iliac occlusive disease. Patients with ruptured aneurysms, due to
the emergency nature of the procedure, the possibility of reduced sterility, bacterial gut translocation, and the immunosuppression that occurs
with critical illness and recovery, may be more
prone to graft infection, especially from skin
ora such as Staphylococcus aureus or
Staphylococcus epidermidis. In addition, extension of an aortic graft to the femoral artery, in
either elective or urgent situations, will signicantly increase the risk of prosthetic graft infection [10]. In many cases, extending the graft to
the femoral artery is unavoidable, but it may be
prudent to compromise and accept a suboptimal
distal target for iliac anastomoses at the time of
ruptured aneurysm repair and return electively
for a stent or bypass to reduce the risk of infection. The other risk factor associated with prosthetic graft infection is wound infection, so
vigilant care of the incisions must be performed
during the recovery time period.
This case also highlights critical technical
features of explantation of infected aortic grafts
and subsequent reconstruction. In a young
patient, such as this 52-year-old, in situ reconstruction would be favored. Although cryopreserved aortic allograft is a good option, it may be
difcult to obtain a long enough segment to
replace from the aorta to the femoral arteries
without tension. In some cases, an aorto-unifemoral and femoral- femoral graft with cryopreserved artery requires a shorter length of conduit.
The “gold standard” of conduit would be neoaortic iliac graft fashioned from bilateral deep femoral vein. Although the procedure often requires
two surgical teams for efciency, the reduction
in reinfection rate may eliminate the numerous
subsequent procedures required if reinfection
occurs, such as in this patient’s case. Although
cryopreserved allograft likely has a decreased
infection risk compared to antibiotic-soaked
prosthetic, cryograft is not immune to reinfection
and typically erodes with infection causing rupture, as in this patient. Other options such as antibiotic-soaked in situ prosthetic would be the third
choice for reconstruction in a 52-year-old.
Regardless of the type of in situ reconstruction,
omental wrap is associated with a reduced risk of
reinfection and should be used in all patients if
available [8]. If not, other autologous tissues,
such as fascia lata, may be harvested and used as
a biological wrap around the graft. It is not indicated in this patient whether an omental wrap
was used. In addition, although not available
in 2007, antibiotic beads, such as Stimulon
®
(Biocomposites Ltd., Staffordshire, England),
may be considered in patients with difcult to
manage prosthetic infection. The beads are
absorbable and can be tailored with antibiotics to
suit the patient’s infection. Although they are
costly and there is no Level 1 data yet, antibiotic
beads are a promising adjunct to the management
of complex aortic graft infection in a patient such
as this one. Finally, the use of intravenous and
oral antibiotics, as well as duration of antibiotics
and the use of suppressive antibiotics, is controversial. Although judicious antibiotic use is
always the best, many patients with chronic
infections may require targeted ongoing suppressive antibiotics to avoid ongoing interventions.
In summary, this patient did well despite
ongoing recurrent infections, each managed successfully. This case highlights that the greatest
risk factor for graft infection is the presence of a
previous infection and why prevention of the initial infection is so important by using careful
attention to all aspects of management.
References
1. O’Connor S, Andrew P, Bat M, Becquemin JP.A sys-
temic review and meta-analysis of treatment for aortic
graft infection. J Vasc Surg. 2006;44:38–45.
2. Kieffer E, Gomes D, Chiche L, Fleron MH, Koskas F,
Bahnini A.Allograft replacement for infrarenal aortic
graft infection: early and late results in 179 patients. J
Vasc Surg. 2004;39:1009–17.
78
20 Prosthetic Graft Infection Following Open Repair ofRuptured Abdominal Aortic Aneurysm
3. Noel AA, Gloviczki P, Cherry KS, Sa H, Goldstone
J, Morasch MD, Johansen KH. Abdominal aortic reconstruction in infected elds. Early results of
United States cryopreserved aortic allograft registry. J
Vasc Surg. 2002;35:847–52.
4. Charlton-Ouw KM, Sandhu HK, Huang G, Leake
SS, Miller CC 3rd, Estrera AL, Azizzadeh A, Sa
HJ.Reinfection after resection and revascularization
of infected infrarenal abdominal aortic grafts. J Vasc
Surg. 2014;3:684–92.
5. Chung J, Clagett GP. Neoaortoiliac system (NAIS)
procedure for the treatment of infected aortic graft.
Semin Vasc Surg. 2011;4:220–6.
6. Berger P, Moll FL.Aortic graft infections: is there still
a role for axillobifemoral reconstruction? Semin Vasc
Surg. 2011;4:205–10.
7. Ali AT, Modrall JG, Hocking J, Valentine RJ, Spencer
H, Eidt JF, Clagett GP. Long-term results of the
treatment of aortic graft infection by in situ replacement with femoral popliteal vein grafts. J Vasc Surg.
2009;1:30–9.
8. Oderich GS, Bower TC, Cherry KJ Jr, Panneton JM,
Sullivan TM, Noel AA, Carmo M, Cha S, Kalra M,
Gloviczki P. Evolution from axillofemoral to in situ
prosthetic reconstruction for the treatment of aortic graft infections at a single center. J Vasc Surg.
2006;6:1166–74.
9. Hans SS.Spiral vein grafts as vascular conduits in
irradiated and contaminated tissue beds. J Am Coll
Surg. 2002;195:732–6.
10. Antonios VS, Noel AA, Steckelberg JM, Wilson WR,
Mandrekar JN, Harmsen WS, Baddour LM.Prosthetic
vascular graft infection: a risk factor analysis using a
case-control study. J Infect. 2006;53:49–55.
Part III
Open Repair of Intact and Ruptured Iliac
Artery Aneurysms
Open Repair ofCommon Iliac
Artery Aneurysm
21
History andPhysical Examination
A 65-year-old male underwent open repair of
3.9cm left common iliac artery aneurysm. There
was associated ectasia of the right common iliac
artery and signicant tortuosity of the infrarenal
aorta diagnosed by CT angiography (Fig.21.1).
Patient was rst seen in 2009 with a 3.5cm transverse diameter abdominal aortic aneurysm, and
in 2014 the aneurysm gradually enlarged to the
present size of 3.9cm.
Procedure
Because of the associated extreme tortuosity of
the left common iliac artery, open repair was preferred over endovascular repair as extreme tortuosity of iliac artery even if straightened by stiff
wire, in all probably, would have led to kinking
of the limb of endograft following removal of the
stiff wire. Since the infrarenal aorta was tortuous
with associated dilatation of the right common
iliac artery and patient’s age, it was decided to
perform open repair. Patient underwent open
repair on April 17, 2014. Through a transperitoneal midline approach, infrarenal aorta was
mobilized, and proximal control was obtained
through the renal arteries. Following incision
along the white line of Toldt, the sigmoid colon
was mobilized proximally, and left common iliac
artery aneurysm was exposed. Right common
iliac artery was ectatic. Right external and hypogastric artery were controlled separately with a
silastic vessel loop. Proximal anastomosis was
performed end to end using an 18 × 9mm knitted
Dacron graft. The right limb of the graft was
anastomosed just below the dilatation of the common iliac artery and near its bifurcation with 4-0
cardiovascular Prolene suture.
After partially resecting anterior wall of the
left common iliac artery aneurysm, the left limb
of the Dacron graft was brought under the sigmoid colon and under the ureter and was
Fig. 21.1 Left common iliac artery aneurysm with tortuosity of aorta and common iliac arteries (posterior view)
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_21
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