David Phang1, Matthew R Smeds2, Matthew Abate3, Ahsan Ali3, Becky Long4, Maham Rahimi1, Joseph Giglia1, Jonathan Bath5. 1. Division of Vascular Surgery, University of Cincinnati Medical Center, Cincinnati, OH. 2. Division of Vascular and Endovascular Surgery, Saint Louis University, Saint Louis, MO. 3. Division of Vascular Surgery, University of Arkansas for Medical Sciences, Little Rock, AK. 4. Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA. 5. Division of Vascular Surgery, University of Missouri Hospital & Clinics, Columbia, MO. Electronic address: bathj@health.missouri.edu.
Abstract
BACKGROUND: Infections of isolated limbs of prosthetic grafts are challenging. Management can be morbid, involving partial or complete removal of all prosthetic material followed by aortic reconstruction. More limited resections of only infected material and reconstruction of the affected iliac limb has been reported as a viable surgical option. We review 2 academic institution's experiences treating limited aortic graft infections by obturator canal bypass (OCB) or hemi-neoaortoiliac system (H-NAIS). METHODS: A retrospective review of OCB at one institution between 1995 and 2013 and H-NAIS at the other institution between 2003 and 2014 was conducted. Demographics, comorbidities, and postoperative and medium-term events were recorded. Outcomes were patency, limb salvage, graft preservation without reinfection, and survival. RESULTS: OCB was performed in 18 limbs and H-NAIS in 34 limbs. The OCB group had a higher prevalence of cancer (40% vs. 10%; P = 0.04). The most common treatment indication was infection of an aortobifemoral bypass limb in both groups. No differences were seen in overall graft infection, with one patient suffering a late graft reinfection (6% of OCB versus 0% in H-NAIS; P = 0.35). There were no perioperative deaths in either group. Regarding major adverse limb events, there were no amputations performed in the perioperative period in either group. The most frequent organism cultured in both OCB and H-NAIS was Staphylococcus aureus. Surgery duration was similar between the groups (OCB 379 ± 115 minutes vs. H-NAIS 370 ± 137 minutes; P = 0.8) as was the length of stay (OCB 10.5 ± 5.3 days vs. H-NAIS 12.4 ± 10.6 days; P = 0.4). At 36 months, there was no difference in primary patency (OCB 45% vs. H-NAIS 63%; P = 0.7), primary-assisted patency (OCB 51% vs. H-NAIS 61%; P = 0.5), or secondary patency (OCB 68% vs. H-NAIS 63%; P = 0.6) between the groups. Endovascular and open reinterventions occurred more frequently in OCB than in H-NAIS (61.1% vs. 23.5%; P = 0.007). There were no differences in overall survival (OCB 83% vs. H-NAIS 81%; P = 0.6), and no significant difference in amputation rate was seen during the follow-up period (OCB 17% vs. H-NAIS 6%; P = 0.35). CONCLUSIONS: OCB and H-NAIS are effective strategies for treatment of limited aortic graft infections with reasonable patency, survival, and limb salvage at medium-term follow-up. Prudent patient selection and institutional experience with aortic graft infection treatment leads to good outcomes with lifelong follow-up recommended. Further study of the optimal treatment strategy for this complex group of patients is needed.
BACKGROUND: Infections of isolated limbs of prosthetic grafts are challenging. Management can be morbid, involving partial or complete removal of all prosthetic material followed by aortic reconstruction. More limited resections of only infected material and reconstruction of the affected iliac limb has been reported as a viable surgical option. We review 2 academic institution's experiences treating limited aortic graft infections by obturator canal bypass (OCB) or hemi-neoaortoiliac system (H-NAIS). METHODS: A retrospective review of OCB at one institution between 1995 and 2013 and H-NAIS at the other institution between 2003 and 2014 was conducted. Demographics, comorbidities, and postoperative and medium-term events were recorded. Outcomes were patency, limb salvage, graft preservation without reinfection, and survival. RESULTS:OCB was performed in 18 limbs and H-NAIS in 34 limbs. The OCB group had a higher prevalence of cancer (40% vs. 10%; P = 0.04). The most common treatment indication was infection of an aortobifemoral bypass limb in both groups. No differences were seen in overall graft infection, with one patient suffering a late graft reinfection (6% of OCB versus 0% in H-NAIS; P = 0.35). There were no perioperative deaths in either group. Regarding major adverse limb events, there were no amputations performed in the perioperative period in either group. The most frequent organism cultured in both OCB and H-NAIS was Staphylococcus aureus. Surgery duration was similar between the groups (OCB 379 ± 115 minutes vs. H-NAIS 370 ± 137 minutes; P = 0.8) as was the length of stay (OCB 10.5 ± 5.3 days vs. H-NAIS 12.4 ± 10.6 days; P = 0.4). At 36 months, there was no difference in primary patency (OCB 45% vs. H-NAIS 63%; P = 0.7), primary-assisted patency (OCB 51% vs. H-NAIS 61%; P = 0.5), or secondary patency (OCB 68% vs. H-NAIS 63%; P = 0.6) between the groups. Endovascular and open reinterventions occurred more frequently in OCB than in H-NAIS (61.1% vs. 23.5%; P = 0.007). There were no differences in overall survival (OCB 83% vs. H-NAIS 81%; P = 0.6), and no significant difference in amputation rate was seen during the follow-up period (OCB 17% vs. H-NAIS 6%; P = 0.35). CONCLUSIONS:OCB and H-NAIS are effective strategies for treatment of limited aortic graft infections with reasonable patency, survival, and limb salvage at medium-term follow-up. Prudent patient selection and institutional experience with aortic graft infection treatment leads to good outcomes with lifelong follow-up recommended. Further study of the optimal treatment strategy for this complex group of patients is needed.