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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3710_Библиотеки_им_академика_М_И_Перельмана.pdf
Exposed Femoral Graft Following Multiple Arterial Reconstruction
51
History andProcedures
A 64-year-old male presented to outpatient clinic
with exposed left femoral graft following a recent
(3-week-old) crossover right femoral to left popliteal (8 mm INTERING® PTFE – W.L. Gore,
Newark, DE) graft. Past medical history was signicant for hypertension and nicotine abuse (60
pack years). Patient had undergone multiple arterial reconstructions in the past 15years. In 2002
the patient underwent bilateral iliac stenting: on
the left common iliac stent (39mm × 7mm) and
right common iliac stent (29 mm × 7 mm)
Palmaz® GENESIS™ balloon expandable stents
(Cardinal Health, Dublin OH). By 2003, the
stenting had failed, and the patient underwent an
aortobifemoral bypass graft using a 16 × 8mm
knitted Dacron graft for symptomatic iliac artery
occlusive disease. Proximal aortic anastomosis
was performed end to end. In 2009, patient developed thrombosis of the left limb of the graft
requiring revision. In 2010, patient underwent
right supercial femoral artery and popliteal
angioplasty with stent placement. He presented
in 2011 with a cold right foot and had developed
thrombosis of the distal supercial femoral artery
including the stent, and a right femoral-popliteal
in situ bypass was performed. In 2015, patient
underwent thrombectomy of the left limb of the
aortobifemoral bypass graft extending to supercial and deep femoral arteries after he presented
with a painful numb left lower extremity. Patient
was seen again in June 2016 with a cold left leg
and underwent left femoral to popliteal nonreversed great saphenous vein bypass secondary
to supercial femoral artery thrombosis and a
poor outow from branches of the deep femoral
artery.
In August 2016 patient was seen as an outpa-
tient and was found to have supercial left groin
wound dehiscence with small amount of serosanguinous drainage. The seroma was drained; cultures were positive for Staphylococcus aureus,
coagulase negative, and Streptococcus viridans.
The following day the patient presented with
bleeding from the left groin wound. He was noted
to have a two-centimeter opening without
exposed graft, with no active bleeding. However,
there was surrounding induration. The patient
was started on IV antibiotics Vancomycin and
Zosyn, and a CTA was performed. The CTA
demonstrated a patent aortobifemoral, bilateral
femoral-popliteal bypasses, and left groin inammatory changes with aneurysmal dilatation of the
distal aortic limb graft without extravasation
(Fig.51.1).
The patient was scheduled for a debridement
on the left groin with sartorius muscle ap on
hospital day 4; however, on hospital day three,
patient developed secondary hemorrhage in the
left groin. He underwent emergent debridement
of the skin and soft tissue and revision of the left
femoral-popliteal bypass with takedown of the
proximal anastomosis with a new anastomosis
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_51
215
216
Fig. 51.1 Left unilateral limb of the aortobifemoral graft
infection with soft tissue thickening in the left groin,
aneurysmal dilatation, and small amount of gas seen
around the graft
51 Exposed Femoral Graft Following Multiple Arterial Reconstruction
extending into the proximal supercial femoral
artery, with sartorius muscle ap and a wound
vac therapy. At this time, cultures did not show
any growth of microorganisms. On hospital day
ten, patient was discharged with stable hemoglobin and hematocrit and continued negative pressure therapy and oral rifampin with IV Ancef for
6 weeks per recommendation of the infectious
disease consultant.
Seven days later the patient presented again to
the emergency department with active hemorrhage from the left groin. He was hypotensive
with acute blood loss, anemia, and stage III hemorrhagic shock. He was taken to the operating
room where bleeding was noted from the anastomotic suture line of the distal left limb of the aortobifemoral bypass graft. The patient underwent
removal of the left infected unilateral limb of the
aortobifemoral bypass graft with suture ligation
of the proximal graft and placement of wound
vac. There were no Doppler arterial ows in the
posterior tibial or the dorsalis pedis arteries.
Cultures at this time grew vancomycin-resistant
Enterococcus faecalis (VRE) and Candida
parapsilosis.
Following a performance of a left axillopopliteal bypass 2 weeks later with an 8mm INTERING
PTFE graft (W.L.Gore Inc., Newark, DE), patient
regained posterior tibial Doppler signals. During
his hospital stay, he was continued on intravenous
antibiotics. A repeat CTA was performed on postoperative day 9 showing a patent left axillopopliteal bypass. He was discharged on post-operative
day 14 with continued negative pressure therapy
to his left groin, IV daptomycin, and PO Diucan
for an additional 4 weeks. Patient was ambulating
and continued to do well till his follow-up visit
with palpable dorsalis pedis pulses.
On May 23, 2017, patient presented to the
emergency room with cold pulseless left lower
extremity. Doppler arterial study and CTA of the
chest/abdomen showed occluded axillopopliteal
bypass with no Doppler ow in the left foot.
Patient underwent crossover femoral-popliteal
(proximal) graft with 8 mm INTERING PTFE
graft. A tunnel was made in the suprapubic space
with 8mm tunneler.
Right limb of the well-incorporated Dacron
graft and origin of the right femoral-popliteal in
situ bypass were exposed, and popliteal artery
just above the left knee joint was exposed and
mobilized following transection of the medial
head of the gastrocnemius. On the right-side
crossover graft was sutured near the hood of the
femoral-popliteal in situ bypass in an end-to-side
fashion, and distal anastomosis to the popliteal
artery was also performed in an end-to-side fashion (Fig. 51.2). Patient regained left dorsalis
pedis pulse on the left foot. Patient presented to
the clinic 3 weeks later with exposed PTFE graft
in the left groin. Since sartorius muscle had
already been used, patient underwent gracilis
muscle ap with a split thickness skin graft and
application of wound vac on June 13, 2017
(Fig. 51.3). Complete healing and coverage of
the graft in the subsequent 3 weeks occurred
(Fig. 51.4). Vascular lab study in May 2018
revealed an ankle brachial index of 0.85 on the
right and 0.69 on the left. Patient was last seen in
June 2019 with satisfactory healing and no clinical evidence of graft infection. Patient presented
to the emergency room with the symptoms of
acute lower limb ischemia secondary to thrombosed cross-over right common femoral to left
popliteal graft in March 2020. Following a failed
thrombectomy, patient underwent left above knee
amputation and will be tted with above knee
prosthesis in April 2020.
Discussion
217
Fig. 51.3 Exposed PTFE graft and gracilis muscle ap
Fig. 51.2 CTA of the chest and abdomen showing patent
aorto-right femoral graft, ligated left limb of aortobifemoral graft. Patent right femoral-popliteal in situ bypass and
left axillopopliteal bypass
Discussion
Aortic graft infections can be classied as (1A)
early infection which is dened as manifesting
less than 4 months from time of initial surgery.
These infections tend to be of a higher grade
with high virulence, or (1B) late infection is
dened as greater than 4 months from time of
initial surgery and is usually low grade with
lower virulence. Graft infection occurs either by
direct infection or by hematogenous seeding
[1–4]. Although perioperative contamination is
Fig. 51.4 Satisfactory left groin healing
a frequent cause of infection, almost 50% of
infections occur 25–70months following arterial reconstruction [5–7]. The most common
218
51 Exposed Femoral Graft Following Multiple Arterial Reconstruction
organisms are gram- positive organisms with
Staphylococcus aureus predominating. Other
common organisms are coagulase-negative
staphylococci, streptococci, enterococci, and
other gram-negative organisms (Pseudomonas,
E. coli, Bacteroides).
The risk factors for aortic graft infection
include but are not limited to prolonged operative
time (greater than 4 hours), perioperative infection at a different site, nasal carrier of staphylococci, older age, female gender, critical limb
ischemia, obesity, chronic obstructive pulmonary
disease, hyperglycemia, malnutrition, end-stage
renal disease, immunodeciency, an infected
thrombus within an aortic aneurysm, inadequate
choice/dosing/timing of perioperative antibiotics,
breaks in sterile technique, tissue trauma, bacteremia, and surgical site infections.
Multiple classication systems have been presented to delineate type of aortic graft infection.
Two most common classications used are by
Szilagyi and Samson. According to Szilagyi’s
classication, Grade (I) infection represents
supercial infection with cellulitis involving the
wound, Grade (II) deep infection involving subcutaneous tissue, and Grade (III) graft infections
[8]. Samson classication Grade (I) infection
limited to dermis, Grade (II) infection involving
subcutaneous tissue, Grade (III) infection of the
graft not involving the anastomosis, Grade (IV)
infection involving the anastomosis but no bleeding or bacteremia present, and Grade (V) infection involving anastomosis with bleeding and/or
hemorrhage [6].
The main principle in treatment of aortic graft
infection is debridement of surrounding infected
tissue, excision of the graft, and secondary revascularization. Antibiotics play a key role in the
treatment of these patients but are usually given
for a time period of about 6 weeks. The gold standard in the past for aortic graft infection was
removal of the graft with an axillary-bifemoral
bypass revascularization. The axillary-bifemoral
bypass however is associated with a mortality of
25–40%, risk of aortic stump blowout (mortality
30%), graft thrombosis, poor long-term patency
rates, and reinfection rates of 5–15%. In lieu of
these outcomes, more recent literature has shown
that in situ reconstruction, debridement with or
without muscle ap, is superior in terms of perioperative mortality, limb amputations, and reinfection rates [9]. The in situ revascularization can
be performed with cryopreserved allograft, autologous femoral-popliteal veins (deep veins), spiral
vein grafts, rifampicin-soaked or silver-coated
Dacron, or PTFE grafts. Nonetheless, extraanatomical bypass grafts can by utilized in cases
of inaccessible groin, hostile abdomens, and
presence of severe comorbidities.
In patients with severe comorbidities, a more
conservative approach with antibiotics, local
debridement, muscle ap, and negative pressure
therapy may be undertaken. In order to attempt to
salvage the graft, it should be surrounding by
healthy, non-infected viable tissue. In a retrospective study by Ryu etal., the sartorius muscle
ap provided coverage in the setting of soft tissue
groin infections following a lower extremity
revascularization [5]. In patients with nonavailability of sartorius muscle ap (as was in this
patient), gracilis muscle ap is a suitable alternative. Morasch etal. placed gracilis muscle ap in
18 patients with a failed graft in 2 patients at a
mean follow-up of 40±10months. There was no
recurrence of graft infection in their series [10].
Other muscle aps which can be used for coverage of exposed grafts are the rectus femoris and
tensor fascia lata. Anastomotic aneurysm of
suture line hemorrhage, systemic sepsis, or
aggressive bacterial infections (gram-negative
infections) are contraindications to conservative
management.
In patients with aortobifemoral graft, who
present with a unilateral graft limb infection, a
unilateral graft limb excision with revascularization or complete graft removal can be attempted.
In a retrospective study, Crawford etal. demonstrated unilateral limb excision can be excised,
provided infection is infrainguinal. In their study,
50% of the patients developed a subsequent
infection in the main body or a contralateral limb
at a median of 2 years after unilateral graft limb
excision [2]. Factors predictive of contralateral
limb or main body graft infection are culture positive supra-inguinal graft infection and an original aortobifemoral graft placed for aortoiliac
References
219
occlusive disease. However, microbes cultured in
supra-inguinal infections were unique from
microbes causing recurrent graft infections in
this study raising suspicion for a new infection in
the contralateral limb.
In patients with an inaccessible groin (either
secondary to infection or multiple previous interventions), an in situ bypass or extra-anatomic
bypass to the groin cannot be performed. Met
et al. reported extra-anatomical bypass in 24
patients, specically axillopopliteal bypass for
limb salvage in setting of inaccessible groin over
an 11-year period [3]. Several case studies since
the 1970s have shown 1-year patency of 58–77%
with a limb salvage rate at 1 year of 65–86%.
However, in a small study by Seeger etal., there
was 100% graft thrombosis with 0% primary
patency at 7 months [7]. Met etal. emphasized
the overall disease condition along with technical
surgical aspects may dictate the primary patency
of the graft [3]. However there is limited data
regarding 1-year patency rate of axillopopliteal
bypass. In our patient, axillopopliteal bypass
occluded 9 months following reconstruction, and
patient subsequently underwent crossover
femoral- popliteal bypass graft which has
remained patent for the past 2 years and 3 months
without any evidence of infection involving the
main body of the right aortic limb. In most
patients with infected limb with aortobifemoral
graft, it is important to remove the entire graft.
However, in this patient, the right limb was well
incorporated and in the absence of any recurrence
of infection. Keeping the main body and the right
limb of the graft may occasionally be feasible.
reconstruction such as axillopopliteal or crossfemoral- popliteal bypasses can sometimes act
more like a disease than a cure given their exceedingly high thrombosis rates. In most circumstances, in-line, in situ, anatomic revascularization
may be a better alternative, despite higher recurrent infection rates, especially when prosthetic
material is required. In order to achieve success
with in situ reconstruction, bacterial isolates need
to be minimally virulent in type, and new graft
material must be sufciently covered by a wellperfused muscle ap. There are a number of suitable options for muscle ap coverage of graft
material in the groin region. Of those options, the
gracilis muscle is best suited for this purpose as
its blood supply is derived from branches of the
deep femoral artery which generally remains patent following any bypass reconstruction to the
groin. Alternatives, including rectus muscle aps,
which derive perfusion from the inferior epigastric artery and sartorius muscle with its supercial femoral artery blood supply, have oftentimes
lost their source of direct blood supply. In addition, depending upon harvest techniques, the
length of the gracilis muscle and the ability to
mobilize it long distances on its pedicle make this
tissue source the best option for covering large
defects, even those that extend proximal to the
inguinal ligament. Prosthetic graft infections are
always vexing problems, and while virulent bacterial isolates will generally mandate complete
removal of all prosthetic, with careful technique,
close follow-up and a bit of luck patients with
less virulent infections can oftentimes get by, and
limbs may be preserved, with partial excision and
either extra anatomic or in situ revascularization.
Invited Commentary fromMark
D.Morasch, MD, FACS, RPVI
This is obviously a very challenging case and
very complex problem. The authors should be
congratulated for their perseverance and persistence. I suspect that many vascular surgeons
would have thrown their hands up at some point,
ligated the conduit, removed the infected prosthetic, and accepted amputation as an ultimate
result. That said, long segment extra-anatomic
References
1. Calligaro KD, Veith FJ, Yuan JG, et al. Intraabdominal aortic graft infection: complete or partial
graft preservation in patients at very high risk. J Vasc
Surg. 2003;38:1199–205.
2. Crawford JD, Landry GJ, Moneta GL, etal. Outcomes
of unilateral graft limb excision for infected aortobifemoral graft limb. J Vasc Surg. 2016;63:407–13.
3. Met R, Hissink RJ, Van Reedt Dortland RWH, etal.
Extra-anatomical reconstruction in the case of an inac-
220
51 Exposed Femoral Graft Following Multiple Arterial Reconstruction
cessible groin: the axillo-popliteal bypass. Ann Vasc
Surg. 2007;21:240–4.
4. O’Connor S, FRCP H, Andrew P, et al. A systemic
review and meta-analysis of treatments for aortic graft
infection. J Vasc Surg. 2006;44:38–45.
5. Ryu YD, Jung HJ, Ramaiah VG, et al. Infected groin
(graft/patch): managed with sartorius muscle ap.
Vasc Special Int. 2016;32(1):11–6.
6. Samson RH, et al. A modied classication and
approach to the management of infections involving peripheral arterial prosthetic grafts. J Vasc Surg.
1988;8(2):147–53.
7. Seeger JM, Pretus HA, Welborn BM, etal. Long-term
outcome after treatment of aortic graft infection with
staged extra-anatomic bypass grafting and aortic graft
removal. J Vasc Surg. 2000;32:451–61.
8. Szilagyi DE, Smith RF, Elliott JP, Vrandecic
MP.Infection in arterial reconstruction with synthetic
grafts. Am Surg. 1972;176:321–33.
9. Armstrong PA, Back MR, Bandyk DE, etal. Selective
application of sartorius muscle aps and aggressive
staged surgical debridement can inuence long term
outcomes of complex prosthetic graft infection. J Vasc
Surg. 2007;46(1):71–8.
10. Morasch MD, Sam AD, Kibbie MR, Dumaniau
MJ.Early results with the use of gracilis muscle ap,
coverage of infected groin wounds after vascular surgery. J Vasc Surg. 2004;39(6):1277–83.
Complications (Early andLate)
ofAortofemoral Grafting
52
History andPhysical Examination
A 62-year-old male was seen in the outpatient
clinic on January 2012 with symptoms of bilateral lower extremity claudication (hips and
thighs) on walking 50 yards. He complained of
erectile dysfunction. Medical comorbidities
included hypertension, chronic obstructive pulmonary disease, and nicotine abuse (60 pack
years). Bilateral femoral, popliteal, tibial, and
dorsalis pedis pulses were absent. Non-invasive
Doppler study revealed an ankle brachial index
on the right was 0.52 and on the left 0.34. CTA
showed infrarenal aortic occlusion with occlusion of both common iliac arteries and aneurysmal hypogastric arteries (Fig.52.1).
Procedure
He underwent aorto-bifemoral graft (16×8mm
knitted Dacron reconstruction) on January 29,
2012 for thrombosed aortic aneurysm (diameter
3.5cm). Thrombosis extended from 1 centimeter
below the origin of the renal arteries. Postoperative course was complicated by respiratory
failure secondary to pneumonia requiring ventilatory support for 3 days. He also noticed weakness of the right lower extremity with inability to
lift it against gravity. Following ICU stay, patient
was transferred to regular medical/surgical oor.
He was started on physical and occupational therapy. Patient had palpable pulses in both feet.
Non-invasive Doppler arterial study in June 2013
showed ankle brachial index of 1.01 on the right
and 1.02 on the left. For the rst 2 months following arterial reconstruction, he needed a right knee
brace as the quadriceps muscle was weak but
within 6 months regained normal motor function
of the right lower extremity.
Patient did not come to follow-up for 5 years
till July 2019 as he developed ischemic rest pain
in the right foot with painful ulceration following
sustaining trauma to the skin tendo Achilles
(Fig.52.2). Non-invasive Doppler arterial study
showed an ankle brachial index on the right 0.3
and on the left 0.5. In addition, bilateral masses
were palpable in both groins. Duplex imaging of
the groin showed a partially thrombosed anastomotic aneurysm measuring 3.0cm in diameter on
the right and 2.5 cm on the left. Aortogram in
July 2019 showed patent aorto-bifemoral graft,
right common femoral artery occlusion, and
proximal and mid-segment right supercial femoral artery occlusion. There was reconstitution of
popliteal artery on the right above the knee with
runoff primarily with anterior tibial artery in the
calf extending with continuation of the dorsalis
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_52
221
222
52 Complications (Early andLate) ofAortofemoral Grafting
Fig. 52.1 CTA showing infrarenal aortic occlusion, bilateral common iliac, and hypogastric artery
artery as a long spatulated anastomosis was performed. Patient also underwent simultaneous
right femoral-popliteal in situ bypass (Fig.52.4).
In post-operative period, patient developed swelling of the lower extremity which subsided with
elevation and use of elastic support below the
knee.
Discussion
Aorto-bifemoral graft reconstruction in a patient
Fig. 52.2 Showing ischemic ulcer, right heel
pedis artery (Fig. 52.3). On August 8, 2019,
patient underwent resection of the right femoral
anastomotic aneurysm with removal of large
amount of thrombus with interposition of a 5-cmlong 8-mm-diameter knitted Dacron graft sutured
proximally to the previously placed Dacron graft.
An end-to-end anastomosis to the deep femoral
was complicated by spinal cord ischemia with
weakness of the muscles of the right thigh. This
probably represents ischemia/infarction of the
right lumbosacral root (Type III) as described in
Chap. 10 [1]. This patient had aortic occlusion
(thrombosis of a small diameter abdominal aortic
aneurysm) and occlusion of both common iliac
and aneurysmal hypogastric arteries. During aortic reconstruction, it is likely that patient had
interruption of collateral circulation to the pelvic
Discussion
223
Fig. 52.3 Showing aortography with patent aorto-bifemoral graft, right supercial femoral artery occlusion
vasculature. This situation was unavoidable as
distal segments of the hypogastric artery were not
available for reconstruction of a separate bypass
from limbs of the aortic graft. Fortunately, patient
recovered from motor weakness and was
ambulating without cane after 6 months of arterial reconstruction.
Femoral anastomotic aneurysms are described
in Chap. 25. Femoral anastomotic aneurysms
present as asymptomatic pulsatile masses about
typically 5–10 years aortofemoral graft reconstruction. Local pressure symptoms (pain, femoral neuralgia) may be present. Thrombosis and
rupture of the femoral anastomotic aneurysms are
uncommon. In this patient, thrombosis of the right
femoral anastomotic aneurysm with associated
right supercial artery occlusion resulted in critical limb ischemia which was managed by revision
of the right limb of the graft, removal of the anastomotic aneurysm, and anastomosis of the Dacron
limb to the deep femoral artery. Patient also
underwent simultaneous right femoral- popliteal
in situ bypass resulting in restoration of arterial
supply to the right lower extremity. Repair of femoral anastomotic aneurysm is indicated once the
aneurysm reaches the size of 3cm or larger. The
incidence of femoral anastomotic aneurysms is
decreasing as fewer aorto-bifemoral grafts for
iliac artery occlusive disease are being performed.
This is the result of increasing use of percutaneous interventions (iliac angioplasty and stenting)
for aortoiliac artery occlusive disease.
224
52 Complications (Early andLate) ofAortofemoral Grafting
Fig. 52.4 Repair of thrombosed right femoral anastomotic aneurysm and right femoral-popliteal in situ bypass
Invited Commentary fromPeter
K.Henke, MD
likely in this case), from internal iliac embolization, and could have been worsened with hypo-
tension. The incidence of paralysis with open
Aortofemoral bypasses for aortoiliac disease
have decreased markedly in frequency over the
last 10–15 years given the advent of advanced
endoluminal techniques [2]. In general, this
approach is logical and is likely to reduce at least
early morbidity and mortality and in general
doesn’t burn a bridge for patients who may need
an open procedure later. In the current case, open
aortofemoral bypass (AFB) still remains the best
option for an occluded abdominal aortic aneurysm with concomitant iliac disease. The patient
had small internal aortic aneurysms, but these
were patent and did not merit treatment.
The complication presented was an ischemic
spinal episode with temporary paresis and is
quite unusual [3]. Potential etiologies in this
patient include sacrice of critical spinal collaterals with the infrarenal graft placement (most
AAA is less than 1%. Occasionally these are
purely idiopathic and no denable cause can be
found. Treatment is supportive as was done in
this case, with reasonable recovery.
Anastomotic pseudoaneurysms after AFB
are fairly common. These are particularly common as these grafts age, after 5 or more years.
Many are mild dilatations and don’t reach the
size threshold of 2.5–3.0cm. There is little clear
evidence for size to repair, but generally if they
are associated with embolization or thrombosis,
that is a clear indication for repair, regardless of
size. Typically, repairs are performed using an
interposition graft, as was described in the case,
and hooded down the profunda. This is optimal
and no good endovascular options exist.
Secondly, if further revascularization is required,
the patient can then have a bypass either off the